HospitalInspections.org

Based on observation and interview it was determined the facility failed to properly identify the location of one, two-hour fire rated common wall on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, at 9:04 AM, revealed the facility could not clearly and precisely identify the location of the two-hour fire rated common wall adjoining to building number 17 on the second floor. Facility to provide documentation as to the exact location of the two-hour fire rated common wall.

Interview with maintenance director on January 5, 2011, at 9:05 AM, confirmed the common wall with building number 17 was not accurately identified.

1. Based on observation and interview it was determined the facility failed to limit the use of combustible construction materials on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, at 8:49 AM, revealed large quantities of 1 inch by 3 inch combustible wood furring strips and cellulose ceiling tiles above the suspended ceiling assembly in the west unit that houses the library.

Interview with safety manager on January 5, 2011, at 8:50 AM, confirmed this combustible material is typical of the abandoned-in-place ceiling found throughout the West side, unit C.


2. Based on observation and interview it was determined the facility failed to properly maintain required fire rated construction on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, between 8:15 AM and 8:30 AM, revealed the following:

1. 8:15 AM - Third floor, room 3062's closet had a large penetration in the fire rated ceiling.

2. Third floor, room 3052A, ceiling tiles missing in the fire rated ceiling.

Interview with maintenance director on January 5, 2011, at 8:31 AM, confirmed these rated ceilings had either penetrations or were missing tiles.

Based on observation and interview it was determined the facility failed to properly maintain fire rated floor and ceiling assemblies on two of two floors in this component.

Findings include:

A. Observation on January 3, 2011, between 11:00 AM and 12:00 PM, revealed the second floor suspended ceiling assembly lacked the required protective fire bonnets on the following items:

1. 11:00 AM - All second floor exit corridor recessed lighting fixtures.

2. 11:59 AM - Second floor exit corridor bubble mirror.

Interview with maintenance director on January 3, 2011, at 12:00 PM, confirmed the breaches in the rated ceiling assembly.

B. Observation on January 3, 2011, at 1:15 PM, revealed the concrete floor had been chipped out around pipe penetrations in pipe chase number 04-1-3-015; thereby compromising the one-hour fire resistance rating of the floor.

Interview with maintenance director on January 3, 2011, at 12:00 PM, confirmed the floor was damaged and not continuous in the area around the piping.

Based on observation and interview it was determined the facility failed to properly maintain hourly fire rated construction components on one of two of three levels in this component.

Findings include:

A. Observation on January 3, 2011, at 2:15 PM, revealed the second floor, roof-ceiling assembly did not provide the required one-hour fire resistance rating needed for this type of construction.

Interview with maintenance director on January 3, 2011, at 2:16 PM, confirmed the lack of a one-hour fire resistance rating in the second floor roof-ceiling assembly.


B. Observation on January 3, 2011, at 2:20 PM, revealed the basement level, ceiling-floor assembly did not provide the required two-hour fire resistance rating needed for this type of construction under the first floor mid-level stair risers.

Interview with maintenance director on January 3, 2011, at 2:21 PM, confirmed the lack of a two-hour fire resistance rating in the basement roof-ceiling assembly.

Based upon observation and interview, it was determined the facility failed to maintain building construction requirements in three locations within this component.

Findings include:

A. Observation of building construction on January 04, 2011, between 9:20 AM and 2:10 PM revealed:

1. 9:20 AM - The Ward #2 patio smoking area had combustible material including vinyl soffit and a wooden post used in the construction of the smoking area.

2. 1:10 PM - The South West outside entrance had combustible material (vinyl soffit) used in the construction of this entrance.

3. 2:10 PM - The South East outside entrance had combustible material (vinyl soffit) used in the construction of this entrance.

Interview with Safety Manager on January 04, 2011, at 2:11 PM confirmed that combustible building materials were used within a structure that is designated as noncombustible.

Based on observation and interview it was determined the facility failed to properly maintain corridor walls in seven of ten smoke compartments in this component.

Findings include:

A. Observation on January 4, 2011, between 8:10 AM and 2:10 PM, revealed the following deficiencies:

1. 8:10 AM - Ward 7, corridor wall adjacent to room 1134 does not completely extend to the deck above. Typical for all corridor walls in this component.

2. 2:10 PM - Ward 4, corridor wall adjacent to room 1034 does not completely extend to the deck above. Typical for all corridor walls in this component.

Interview with maintenance director on January 4, 2011, at 2:11 PM, confirmed corridor walls throughout this component do not extend completely to the deck above in the area between the top of the wall and the corrugated deck.

Based on observation and interview it was determined the facility failed to properly configure corridor doors in one of six smoke compartments in this component.

Findings include:

A. Observation on January 3, 2011, at 11:30 AM, revealed second floor women's shower corridor door has a transfer grill. The room is being utilized to store soiled linen.

Interview with maintenance director on January 3, 2011, at 11:31 AM, confirmed this area was used as a storage area.

Based on observation and interview it was determined the facility failed to properly maintain one vertical enclosure on one of three levels in this component.

Findings include:

A. Observation on January 3, 2011, at 1:40 PM, revealed the underside of the stair tower treads were exposed in basement room number B43B3005; thereby compromising the required one-hour fire resistance rating of the separation.

Interview with maintenance director on January 3, 2011, at 1:41 PM, confirmed the stair tower was not adequately separated.

Based on observation and interview it was determined the facility failed to properly maintain vertical enclosures on three of four levels in this component

Findings include:

A. Observation on January 5, 2011, between 8:00 AM and 8:50 AM, revealed the following vertical enclosure deficiencies:

1. 8:00 AM - Basement level, exit stair tower door number 2 did not close and latch in its frame when released.

2. 8:07 AM - First floor, environmental storage area ceiling adjacent to the slop sink had a vertical penetration around a 1-inch diameter copper pipe.

3. 8:28 AM - First floor, handicap lift access door which opens into the exit stair tower enclosure, lacks a required self closing device.

4. 8:40 AM - Third floor, room 3031, had a vertical penetration in the plaster ceiling measuring 2 feet by 3 feet.

5. 8:50 AM - Third floor, bathroom 3020, had a vertical penetration in plaster ceiling.

Interview with safety manager and maintenance director on January 5, 2011, at 8:51 AM, confirmed these vertical penetrations.

Based upon observation and interview, it was determined the facility failed to maintain vertical openings in nine instances in the facility.

Findings include:

Observation of vertical openings on January 04, 2011, between 7:30 AM and 2:20 PM revealed the nine pipe chamber enclosures had walls which were not complete to the deck above.

Interview with the Safety Manager on January 04, 2011, at 2:21 PM confirmed the enclosures were not complete to the deck above.

Based on observation and interview it was determined the facility failed to properly maintain one of eight smoke barrier walls in this component.

Findings include:

A. Observation on January 4, 2011, at 8:55 AM, revealed the smoke barrier wall, located at Ward 6 leading to Administration, had exposed loose fill insulation at the top of the wall that did not provide at least a one half hour fire resistance rating.

Interview with maintenance director on January 4, 2011, at 8:56 AM, confirmed the smoke barrier wall did not provide the proper fire resistance rating.

Based on observation and interview it was determined the facility failed to properly configure four hazardous areas in three of ten smoke compartments in this component.

Findings include:

A. Observation on January 4, 2011, between 8:40 AM and 1:16 PM, revealed the following hazardous area deficiencies:

1. 8:40 AM - First floor, supply closet number 1078, lacks fire rated door with self closing device.

2. 8:51 AM - First floor, supply closet number 1093, lacks fire rated door with self closing device.

3. 1:16 PM - Basement, two caged storage areas open to large area of basement that exceeds the allowable 10,000 square feet.

Interview with maintenance director on January 4, 2011, at 1:17 PM confirmed these hazardous areas lacked the required one hour enclosure.

Based on observation and interview it was determined the facility failed to properly configure one hazardous area in six of six smoke compartments in this component.

Findings include:

A. Observation on January 3, 2011, between 11:45 AM and 11:48 AM revealed the following:

1. 11:45 AM - Second floor room 2044, an area containing large quantities of combustible storage items, was not properly configured as a hazardous are which lacked a required one-hour fire resistance enclosure.

2. 11:48 AM - The corridor door to the second floor room 2044, an area containing large quantities of combustible storage items, did not have the required self-closing device.

Interview with maintenance director on January 3, 2011, at 11:46 AM, confirmed the room did not have a 1-hour rated ceiling assembly, nor did it have the required self-closing device on the corridor door.

Based on observation and interview it was determined the facility failed to properly configure three hazardous areas on two of three floors in this component.

Findings include:

A. Observation on January 5, 2011, between 9:10 AM and 9:43 AM, revealed the following:

1. 9:10 AM - Third floor, room 3014, large room used for combustible storage lacked a ceiling providing the required one-hour fire resistance rating.

2. 9:11 AM - Third floor, room 3014, large room used for combustible storage lacked a required fire rated door and self-closing device.

3. 9:20 AM - Third floor, room 3019B, room used for combustible storage lacked a required self-closing device on the fire rated corridor door.

4. 9:42 AM - Second floor, pharmacy storage room, lacked a required fire rated door and self-closing device.

5. 9:43 AM - Second floor, pharmacy storage room, used for combustible storage lacked a ceiling providing the required one-hour fire resistance rating.

Interview with safety manager and maintenance director on January 5, 2011, at 9:44 AM, confirmed these hazardous areas were not properly configured.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas on two of two levels in the component.

Findings include:

A. Observation of hazardous areas on January 04, 2011, between 8:55 AM and 1:30 PM revealed:

1. 8:55 AM - The door to the second floor soiled linen room #2025 lacked a self closing device.

2. 1:30 PM - The first floor fire alarm panel room #1037 lacked a rated door with a self-closing device at the location leading to the high voltage room.

Interview with Safety Manager on January 04, 2011, at 1:31 PM confirmed both doors lacked self-closing devices as well the fire alarm panel room door lacked the proper rating.

Based on observation and interview it was determined the facility failed to properly configure one required exit on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, at 8:46 AM, revealed a horizontal exit, marked door number 15, exited into a non-health care services building.

Interview with safety manager on January 5, 2011, at 8:47 AM, confirmed the horizontal exit discharged into building number 17 which houses the commercial laundry and hospital dietary services which is a non-health care building.

Based on observation and interview it was determined the facility failed to properly configure four of eight exit stair towers serving three floors in this component.

Findings include:

A. Observation on January 5, 2011, between 7:55 AM and 9:44 AM, revealed the following:

1. 7:55 AM -East side, unit A, utilizing an unauthorized covered metal fire escape as a required exit.

2. 8:10 AM - West side, unit A, utilizing an unauthorized covered metal fire escape as a required exit.

3. 8:35 AM -East side, unit C, utilizing an unauthorized covered metal fire escape as a required exit.

4. 9:44 AM -West side, unit C, utilizing an unauthorized covered metal fire escape as a required exit.

Interview with maintenance director on January 5, 2011, at 9:45 AM, confirmed these fire escapes did not meet the exiting requirements for a health care facility.

Based on observation and interview it was determined the facility failed to maintain exiting capabilities in resident room closets in six of six smoke compartments in this component.

Findings include:

A. Observation on January 3, 2011, between 11:08 AM and 1:40 PM, revealed the following:

1. 11:08 AM - Second floor, patient room 2020 closet had an unauthorized padlock and hasp installed; rendering one incapable of exiting the closet from the inside with a one-step process. This configuration was typical for all patient sleeping room closets on this floor.

2. 1:39 PM - First floor, patient room 1016 closet had an unauthorized padlock and hasp installed; rendering one incapable of exiting the closet from the inside with a one-step process. This configuration was typical for all patient sleeping room closets on this floor.

Interview with maintenance director on January 3, 2011, at 1:40 PM, confirmed egress from the patient room closets could be obstructed by the hasp and padlock.

Based on observation and interview it was determined the facility failed to provide continuous lighting to one of two levels in this component.

Findings include:

A. Observation on January 4, 2011, at 2:20 PM, revealed the basement level did not have required continuous lighting in the caged storage portions of the basement corridor.

Interview with maintenance director on January 4, 2011, at 2:21 PM, confirmed two basement locations did not have continuous lighting.

Based on documentation review and interview it was determined the facility failed to conduct an adequate number of health care occupancy required fire drills during the past year.

Findings include:

A. Review of fire drill documentation on January 4, 2011, between 10:35 AM and 11:00 AM, revealed the facility did not have documentation to support conducting the following required fire drills:

1. 10:35 AM - First calendar quarter 2010, first shift.

2. 10:40 AM - First calendar quarter 2010, second shift.

3. 10:45 AM - Second calendar quarter 2010, first shift.

4. 10:50 AM - Second calendar quarter 2010, second shift.

5. 10:55 AM - Second calendar quarter 2010, third shift.

6. 11:00 AM - Third calendar quarter 2010, second shift.

Interview with fire marshal on January 4, 2011, at 11:01 AM, confirmed the facility did not have documentation to support conducting fire drills in 2010 at the frequency required for a health care occupancy.

Based on observation and interview it was determined the facility failed to properly install required sprinkler systems in four instances on two of two levels in the facility.

Findings include:

A. Observation of sprinkler systems on January 04, 2011, between 8:25 AM and 2:15 PM revealed:

1. 8:25 AM - The second floor room #2002, entrance to the break room, lacked sprinkler coverage.

2. 9:10 AM - The second floor resident room cubes #1-6 are not sprinklered where the ceiling height changes approximately 12 inches. Facility to either add sprinkler coverage or obtain written verification from a qualified sprinkler company indicating the existing sprinkler coverage on the lower ceiling area is adequate to cover the upper ceiling area.

3. 1:55 PM - The elevator shaft lacked sprinkler coverage.

4. 2:15 PM - The vestibule located at the main entrance lacked sprinkler coverage.

Interview with Safety Manager on January 04, 2011, at 2:16 PM confirmed the listed locations lacked sprinkler coverage.

Based on observation and interview it was determined the facility failed to properly inspect and test installed sprinkler system components in one of two levels in the component.

Findings include:

Observation of the sprinkler system on January 04, 2011, at 8:27 AM revealed a sprinkler head, located on the second floor room #2004-A, had ceiling paint on one side.

Interview with Safety Manager on January 04, 2011, at 8:28 AM confirmed the painted sprinkler head.

Based on observation and interview it was determined the facility failed to properly implement smoking policy regulations on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, between 8:24 AM and 8:26 AM, revealed unauthorized cigarette smoke emanating from one of two staff bathrooms located in the first floor co-occurring disorders (COD) unit. Due to individual privacy issues, the single user bathroom could only be entered after the occupant left. The strong smell of cigarette smoke remained in the air.

Interview with safety manager on January 5, 2011, at 8:27 AM, confirmed unauthorized cigarette smoking had taken place in the COD bathroom in violation of hospital policy.

Based on observation and interview it was determined the facility failed to properly maintain and configure one of two designated smoking areas in this component.

Findings include:

Observation of the designated smoking area on January 04, 2011, at 9:45 AM revealed the Ward #3 area lacked a metal container with a self closing cover into which ashtrays can be emptied.

Interview with Safety Manager on January 04, 2011, at 9:46 AM confirmed the area lacked the proper receptacle.

Based on observation and interview it was determined the facility failed to properly configure one commercial cooking area on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, between 8:15 AM and 8:22 AM, revealed the following:

1. 8:15 AM - First floor, commissary department, residential cooking range lacks a required commercial dietary exhaust hood. The range located within the snack bar and is being used on a daily basis to prepare food items that are sold to the public.

2. 8:22 AM - First floor, commissary department, residential cooking range lacks a required dietary fire extinguishment system. The range is located within the snack bar and is being used on a daily basis to prepare food items that are sold to the public.

Interview with safety manager on January 5, 2011, at 8:23 AM, confirmed the snack bar was not properly configured as a commercial cooking location.

Based on observation and interview it was determined the facility failed to properly configure the emergency power supply system on two of two floors in this component.

Findings include:

A. Observation on January 3, 2011, at 11:52 AM, revealed the component did not have a required generator derangement signal at a 24-hour attended location.

Interview with maintenance director on January 3, 2011, at 11:53 AM, confirmed this component did not have a emergency generator derangement signal properly located.

Based on observation and interview it was determined the facility failed to properly configure the emergency power supply system on two of two floors in this component.

Findings include:

A. Observation on January 3, 2011, at 2:25 PM, revealed the component did not have a required generator derangement signal at a 24-hour attended location.

Interview with maintenance director on January 3, 2011, at 2:26 PM, confirmed this component did not have a emergency generator derangement signal properly located.

Based on observation and interview it was determined the facility failed to properly configure the emergency power supply system on two of two floors in this component.

Findings include:

A. Observation on January 5, 2011, at 8:15 AM, revealed the component did not have a required generator derangement signal at a 24-hour attended location.

Interview with safety manager on January 4, 2011, at 8:16 AM, confirmed this component did not have a emergency generator derangement signal properly located.

B. Observation on January 5, 2011, at 8:12 AM, revealed the emergency generator was co-located in a first floor mechanical room with a gas fired water heater, two steam converter tanks and a wire caged storage area with a large quantity of combustible cardboard boxes.

Interview with safety manager on January 5, 2011, at 8:13 AM, confirmed the emergency generator was not separated from other unrelated mechanical equipment and combustible storage areas, by an enclosure having a two-hour fire resistance rating.

Based on observation and interview it was determined the facility failed to properly configure the emergency power supply system on two of two levels in this component.

Findings include:

A. Observation on January 4, 2011, at 8:14 AM, revealed the component did not have a required generator derangement signal located at a 24-hour attended location.

Interview with maintenance director on January 4, 2011, at 8:15 AM, confirmed this component did not have an emergency generator derangement signal properly located.

Based on observation and interview it was determined the facility failed to properly maintain the installed electrical distribution system in one room on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, at 7:45 AM, revealed an unauthorized surge suppressor power strip was being utilized to power a coffee pot in room 3076.

Interview with maintenance director on January 5, 2011, at 7:46 AM, confirmed the power strip was in use.

Based on observation and interview it was determined the facility failed to properly maintain the installed electrical distribution system on one of two floors in this component.

Findings include:

A. Observation on January 3, 2011, at 11:05 AM, revealed an unauthorized 3-way outlet multiplier was being utilized in the second floor break room number 2019.

Interview with maintenance director on January 3, 2011, at 11:05 AM, confirmed the unauthorized use of the outlet multiplier.

B. Observation on January 3, 2011, between 11:10 AM and 11:45 AM, revealed the following patient rooms had beds placed against electrical receptacles:

1. 11:10 AM - Second floor, Patient room 2020.

2. 11:45 - First floor, Patient room 1017.

Interview with maintenance director on January 3, 2010, at 11:46 AM, confirmed these beds were in contact with electrical receptacles.

Based on observation and interview it was determined the facility failed to provide electrical wiring and equipment in accordance with NFPA 101, and the National Electrical Code, NFPA 70 on two of two levels in this component.

Findings include:

A. Observation of electrical wiring and equipment on January 04, 2011, between 8:50 AM and 1:25 PM revealed the following:

1. 8:50 AM - Second floor resident room #2022 had a bed placed against a wall electrical receptacle.

2. 1:25 PM - First floor Central Supply break room had a microwave, toaster, and coffee pot plugged into a surge suppressor power strip.

Interview with Safety Manager on January 04, 2011, at 1:26 PM confirmed these electrical conditions.

Based on observation and interview it was determined the facility failed to properly identify the location of one, two-hour fire rated common wall on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, at 9:04 AM, revealed the facility could not clearly and precisely identify the location of the two-hour fire rated common wall adjoining to building number 17 on the second floor. Facility to provide documentation as to the exact location of the two-hour fire rated common wall.

Interview with maintenance director on January 5, 2011, at 9:05 AM, confirmed the common wall with building number 17 was not accurately identified.

1. Based on observation and interview it was determined the facility failed to limit the use of combustible construction materials on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, at 8:49 AM, revealed large quantities of 1 inch by 3 inch combustible wood furring strips and cellulose ceiling tiles above the suspended ceiling assembly in the west unit that houses the library.

Interview with safety manager on January 5, 2011, at 8:50 AM, confirmed this combustible material is typical of the abandoned-in-place ceiling found throughout the West side, unit C.


2. Based on observation and interview it was determined the facility failed to properly maintain required fire rated construction on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, between 8:15 AM and 8:30 AM, revealed the following:

1. 8:15 AM - Third floor, room 3062's closet had a large penetration in the fire rated ceiling.

2. Third floor, room 3052A, ceiling tiles missing in the fire rated ceiling.

Interview with maintenance director on January 5, 2011, at 8:31 AM, confirmed these rated ceilings had either penetrations or were missing tiles.

Based on observation and interview it was determined the facility failed to properly maintain fire rated floor and ceiling assemblies on two of two floors in this component.

Findings include:

A. Observation on January 3, 2011, between 11:00 AM and 12:00 PM, revealed the second floor suspended ceiling assembly lacked the required protective fire bonnets on the following items:

1. 11:00 AM - All second floor exit corridor recessed lighting fixtures.

2. 11:59 AM - Second floor exit corridor bubble mirror.

Interview with maintenance director on January 3, 2011, at 12:00 PM, confirmed the breaches in the rated ceiling assembly.

B. Observation on January 3, 2011, at 1:15 PM, revealed the concrete floor had been chipped out around pipe penetrations in pipe chase number 04-1-3-015; thereby compromising the one-hour fire resistance rating of the floor.

Interview with maintenance director on January 3, 2011, at 12:00 PM, confirmed the floor was damaged and not continuous in the area around the piping.

Based on observation and interview it was determined the facility failed to properly maintain hourly fire rated construction components on one of two of three levels in this component.

Findings include:

A. Observation on January 3, 2011, at 2:15 PM, revealed the second floor, roof-ceiling assembly did not provide the required one-hour fire resistance rating needed for this type of construction.

Interview with maintenance director on January 3, 2011, at 2:16 PM, confirmed the lack of a one-hour fire resistance rating in the second floor roof-ceiling assembly.


B. Observation on January 3, 2011, at 2:20 PM, revealed the basement level, ceiling-floor assembly did not provide the required two-hour fire resistance rating needed for this type of construction under the first floor mid-level stair risers.

Interview with maintenance director on January 3, 2011, at 2:21 PM, confirmed the lack of a two-hour fire resistance rating in the basement roof-ceiling assembly.

Based upon observation and interview, it was determined the facility failed to maintain building construction requirements in three locations within this component.

Findings include:

A. Observation of building construction on January 04, 2011, between 9:20 AM and 2:10 PM revealed:

1. 9:20 AM - The Ward #2 patio smoking area had combustible material including vinyl soffit and a wooden post used in the construction of the smoking area.

2. 1:10 PM - The South West outside entrance had combustible material (vinyl soffit) used in the construction of this entrance.

3. 2:10 PM - The South East outside entrance had combustible material (vinyl soffit) used in the construction of this entrance.

Interview with Safety Manager on January 04, 2011, at 2:11 PM confirmed that combustible building materials were used within a structure that is designated as noncombustible.

Based on observation and interview it was determined the facility failed to properly maintain corridor walls in seven of ten smoke compartments in this component.

Findings include:

A. Observation on January 4, 2011, between 8:10 AM and 2:10 PM, revealed the following deficiencies:

1. 8:10 AM - Ward 7, corridor wall adjacent to room 1134 does not completely extend to the deck above. Typical for all corridor walls in this component.

2. 2:10 PM - Ward 4, corridor wall adjacent to room 1034 does not completely extend to the deck above. Typical for all corridor walls in this component.

Interview with maintenance director on January 4, 2011, at 2:11 PM, confirmed corridor walls throughout this component do not extend completely to the deck above in the area between the top of the wall and the corrugated deck.

Based on observation and interview it was determined the facility failed to properly configure corridor doors in one of six smoke compartments in this component.

Findings include:

A. Observation on January 3, 2011, at 11:30 AM, revealed second floor women's shower corridor door has a transfer grill. The room is being utilized to store soiled linen.

Interview with maintenance director on January 3, 2011, at 11:31 AM, confirmed this area was used as a storage area.

Based on observation and interview it was determined the facility failed to properly maintain one vertical enclosure on one of three levels in this component.

Findings include:

A. Observation on January 3, 2011, at 1:40 PM, revealed the underside of the stair tower treads were exposed in basement room number B43B3005; thereby compromising the required one-hour fire resistance rating of the separation.

Interview with maintenance director on January 3, 2011, at 1:41 PM, confirmed the stair tower was not adequately separated.

Based on observation and interview it was determined the facility failed to properly maintain vertical enclosures on three of four levels in this component

Findings include:

A. Observation on January 5, 2011, between 8:00 AM and 8:50 AM, revealed the following vertical enclosure deficiencies:

1. 8:00 AM - Basement level, exit stair tower door number 2 did not close and latch in its frame when released.

2. 8:07 AM - First floor, environmental storage area ceiling adjacent to the slop sink had a vertical penetration around a 1-inch diameter copper pipe.

3. 8:28 AM - First floor, handicap lift access door which opens into the exit stair tower enclosure, lacks a required self closing device.

4. 8:40 AM - Third floor, room 3031, had a vertical penetration in the plaster ceiling measuring 2 feet by 3 feet.

5. 8:50 AM - Third floor, bathroom 3020, had a vertical penetration in plaster ceiling.

Interview with safety manager and maintenance director on January 5, 2011, at 8:51 AM, confirmed these vertical penetrations.

Based upon observation and interview, it was determined the facility failed to maintain vertical openings in nine instances in the facility.

Findings include:

Observation of vertical openings on January 04, 2011, between 7:30 AM and 2:20 PM revealed the nine pipe chamber enclosures had walls which were not complete to the deck above.

Interview with the Safety Manager on January 04, 2011, at 2:21 PM confirmed the enclosures were not complete to the deck above.

Based on observation and interview it was determined the facility failed to properly maintain one of eight smoke barrier walls in this component.

Findings include:

A. Observation on January 4, 2011, at 8:55 AM, revealed the smoke barrier wall, located at Ward 6 leading to Administration, had exposed loose fill insulation at the top of the wall that did not provide at least a one half hour fire resistance rating.

Interview with maintenance director on January 4, 2011, at 8:56 AM, confirmed the smoke barrier wall did not provide the proper fire resistance rating.

Based on observation and interview it was determined the facility failed to properly configure four hazardous areas in three of ten smoke compartments in this component.

Findings include:

A. Observation on January 4, 2011, between 8:40 AM and 1:16 PM, revealed the following hazardous area deficiencies:

1. 8:40 AM - First floor, supply closet number 1078, lacks fire rated door with self closing device.

2. 8:51 AM - First floor, supply closet number 1093, lacks fire rated door with self closing device.

3. 1:16 PM - Basement, two caged storage areas open to large area of basement that exceeds the allowable 10,000 square feet.

Interview with maintenance director on January 4, 2011, at 1:17 PM confirmed these hazardous areas lacked the required one hour enclosure.

Based on observation and interview it was determined the facility failed to properly configure one hazardous area in six of six smoke compartments in this component.

Findings include:

A. Observation on January 3, 2011, between 11:45 AM and 11:48 AM revealed the following:

1. 11:45 AM - Second floor room 2044, an area containing large quantities of combustible storage items, was not properly configured as a hazardous are which lacked a required one-hour fire resistance enclosure.

2. 11:48 AM - The corridor door to the second floor room 2044, an area containing large quantities of combustible storage items, did not have the required self-closing device.

Interview with maintenance director on January 3, 2011, at 11:46 AM, confirmed the room did not have a 1-hour rated ceiling assembly, nor did it have the required self-closing device on the corridor door.

Based on observation and interview it was determined the facility failed to properly configure three hazardous areas on two of three floors in this component.

Findings include:

A. Observation on January 5, 2011, between 9:10 AM and 9:43 AM, revealed the following:

1. 9:10 AM - Third floor, room 3014, large room used for combustible storage lacked a ceiling providing the required one-hour fire resistance rating.

2. 9:11 AM - Third floor, room 3014, large room used for combustible storage lacked a required fire rated door and self-closing device.

3. 9:20 AM - Third floor, room 3019B, room used for combustible storage lacked a required self-closing device on the fire rated corridor door.

4. 9:42 AM - Second floor, pharmacy storage room, lacked a required fire rated door and self-closing device.

5. 9:43 AM - Second floor, pharmacy storage room, used for combustible storage lacked a ceiling providing the required one-hour fire resistance rating.

Interview with safety manager and maintenance director on January 5, 2011, at 9:44 AM, confirmed these hazardous areas were not properly configured.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas on two of two levels in the component.

Findings include:

A. Observation of hazardous areas on January 04, 2011, between 8:55 AM and 1:30 PM revealed:

1. 8:55 AM - The door to the second floor soiled linen room #2025 lacked a self closing device.

2. 1:30 PM - The first floor fire alarm panel room #1037 lacked a rated door with a self-closing device at the location leading to the high voltage room.

Interview with Safety Manager on January 04, 2011, at 1:31 PM confirmed both doors lacked self-closing devices as well the fire alarm panel room door lacked the proper rating.

Based on observation and interview it was determined the facility failed to properly configure one required exit on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, at 8:46 AM, revealed a horizontal exit, marked door number 15, exited into a non-health care services building.

Interview with safety manager on January 5, 2011, at 8:47 AM, confirmed the horizontal exit discharged into building number 17 which houses the commercial laundry and hospital dietary services which is a non-health care building.

Based on observation and interview it was determined the facility failed to properly configure four of eight exit stair towers serving three floors in this component.

Findings include:

A. Observation on January 5, 2011, between 7:55 AM and 9:44 AM, revealed the following:

1. 7:55 AM -East side, unit A, utilizing an unauthorized covered metal fire escape as a required exit.

2. 8:10 AM - West side, unit A, utilizing an unauthorized covered metal fire escape as a required exit.

3. 8:35 AM -East side, unit C, utilizing an unauthorized covered metal fire escape as a required exit.

4. 9:44 AM -West side, unit C, utilizing an unauthorized covered metal fire escape as a required exit.

Interview with maintenance director on January 5, 2011, at 9:45 AM, confirmed these fire escapes did not meet the exiting requirements for a health care facility.

Based on observation and interview it was determined the facility failed to maintain exiting capabilities in resident room closets in six of six smoke compartments in this component.

Findings include:

A. Observation on January 3, 2011, between 11:08 AM and 1:40 PM, revealed the following:

1. 11:08 AM - Second floor, patient room 2020 closet had an unauthorized padlock and hasp installed; rendering one incapable of exiting the closet from the inside with a one-step process. This configuration was typical for all patient sleeping room closets on this floor.

2. 1:39 PM - First floor, patient room 1016 closet had an unauthorized padlock and hasp installed; rendering one incapable of exiting the closet from the inside with a one-step process. This configuration was typical for all patient sleeping room closets on this floor.

Interview with maintenance director on January 3, 2011, at 1:40 PM, confirmed egress from the patient room closets could be obstructed by the hasp and padlock.

Based on observation and interview it was determined the facility failed to provide continuous lighting to one of two levels in this component.

Findings include:

A. Observation on January 4, 2011, at 2:20 PM, revealed the basement level did not have required continuous lighting in the caged storage portions of the basement corridor.

Interview with maintenance director on January 4, 2011, at 2:21 PM, confirmed two basement locations did not have continuous lighting.

Based on documentation review and interview it was determined the facility failed to conduct an adequate number of health care occupancy required fire drills during the past year.

Findings include:

A. Review of fire drill documentation on January 4, 2011, between 10:35 AM and 11:00 AM, revealed the facility did not have documentation to support conducting the following required fire drills:

1. 10:35 AM - First calendar quarter 2010, first shift.

2. 10:40 AM - First calendar quarter 2010, second shift.

3. 10:45 AM - Second calendar quarter 2010, first shift.

4. 10:50 AM - Second calendar quarter 2010, second shift.

5. 10:55 AM - Second calendar quarter 2010, third shift.

6. 11:00 AM - Third calendar quarter 2010, second shift.

Interview with fire marshal on January 4, 2011, at 11:01 AM, confirmed the facility did not have documentation to support conducting fire drills in 2010 at the frequency required for a health care occupancy.

Based on observation and interview it was determined the facility failed to properly install required sprinkler systems in four instances on two of two levels in the facility.

Findings include:

A. Observation of sprinkler systems on January 04, 2011, between 8:25 AM and 2:15 PM revealed:

1. 8:25 AM - The second floor room #2002, entrance to the break room, lacked sprinkler coverage.

2. 9:10 AM - The second floor resident room cubes #1-6 are not sprinklered where the ceiling height changes approximately 12 inches. Facility to either add sprinkler coverage or obtain written verification from a qualified sprinkler company indicating the existing sprinkler coverage on the lower ceiling area is adequate to cover the upper ceiling area.

3. 1:55 PM - The elevator shaft lacked sprinkler coverage.

4. 2:15 PM - The vestibule located at the main entrance lacked sprinkler coverage.

Interview with Safety Manager on January 04, 2011, at 2:16 PM confirmed the listed locations lacked sprinkler coverage.

Based on observation and interview it was determined the facility failed to properly inspect and test installed sprinkler system components in one of two levels in the component.

Findings include:

Observation of the sprinkler system on January 04, 2011, at 8:27 AM revealed a sprinkler head, located on the second floor room #2004-A, had ceiling paint on one side.

Interview with Safety Manager on January 04, 2011, at 8:28 AM confirmed the painted sprinkler head.

Based on observation and interview it was determined the facility failed to properly implement smoking policy regulations on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, between 8:24 AM and 8:26 AM, revealed unauthorized cigarette smoke emanating from one of two staff bathrooms located in the first floor co-occurring disorders (COD) unit. Due to individual privacy issues, the single user bathroom could only be entered after the occupant left. The strong smell of cigarette smoke remained in the air.

Interview with safety manager on January 5, 2011, at 8:27 AM, confirmed unauthorized cigarette smoking had taken place in the COD bathroom in violation of hospital policy.

Based on observation and interview it was determined the facility failed to properly maintain and configure one of two designated smoking areas in this component.

Findings include:

Observation of the designated smoking area on January 04, 2011, at 9:45 AM revealed the Ward #3 area lacked a metal container with a self closing cover into which ashtrays can be emptied.

Interview with Safety Manager on January 04, 2011, at 9:46 AM confirmed the area lacked the proper receptacle.

Based on observation and interview it was determined the facility failed to properly configure one commercial cooking area on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, between 8:15 AM and 8:22 AM, revealed the following:

1. 8:15 AM - First floor, commissary department, residential cooking range lacks a required commercial dietary exhaust hood. The range located within the snack bar and is being used on a daily basis to prepare food items that are sold to the public.

2. 8:22 AM - First floor, commissary department, residential cooking range lacks a required dietary fire extinguishment system. The range is located within the snack bar and is being used on a daily basis to prepare food items that are sold to the public.

Interview with safety manager on January 5, 2011, at 8:23 AM, confirmed the snack bar was not properly configured as a commercial cooking location.

Based on observation and interview it was determined the facility failed to properly configure the emergency power supply system on two of two floors in this component.

Findings include:

A. Observation on January 3, 2011, at 11:52 AM, revealed the component did not have a required generator derangement signal at a 24-hour attended location.

Interview with maintenance director on January 3, 2011, at 11:53 AM, confirmed this component did not have a emergency generator derangement signal properly located.

Based on observation and interview it was determined the facility failed to properly configure the emergency power supply system on two of two floors in this component.

Findings include:

A. Observation on January 3, 2011, at 2:25 PM, revealed the component did not have a required generator derangement signal at a 24-hour attended location.

Interview with maintenance director on January 3, 2011, at 2:26 PM, confirmed this component did not have a emergency generator derangement signal properly located.

Based on observation and interview it was determined the facility failed to properly configure the emergency power supply system on two of two floors in this component.

Findings include:

A. Observation on January 5, 2011, at 8:15 AM, revealed the component did not have a required generator derangement signal at a 24-hour attended location.

Interview with safety manager on January 4, 2011, at 8:16 AM, confirmed this component did not have a emergency generator derangement signal properly located.

B. Observation on January 5, 2011, at 8:12 AM, revealed the emergency generator was co-located in a first floor mechanical room with a gas fired water heater, two steam converter tanks and a wire caged storage area with a large quantity of combustible cardboard boxes.

Interview with safety manager on January 5, 2011, at 8:13 AM, confirmed the emergency generator was not separated from other unrelated mechanical equipment and combustible storage areas, by an enclosure having a two-hour fire resistance rating.

Based on observation and interview it was determined the facility failed to properly configure the emergency power supply system on two of two levels in this component.

Findings include:

A. Observation on January 4, 2011, at 8:14 AM, revealed the component did not have a required generator derangement signal located at a 24-hour attended location.

Interview with maintenance director on January 4, 2011, at 8:15 AM, confirmed this component did not have an emergency generator derangement signal properly located.

Based on observation and interview it was determined the facility failed to properly maintain the installed electrical distribution system in one room on one of three floors in this component.

Findings include:

A. Observation on January 5, 2011, at 7:45 AM, revealed an unauthorized surge suppressor power strip was being utilized to power a coffee pot in room 3076.

Interview with maintenance director on January 5, 2011, at 7:46 AM, confirmed the power strip was in use.

Based on observation and interview it was determined the facility failed to properly maintain the installed electrical distribution system on one of two floors in this component.

Findings include:

A. Observation on January 3, 2011, at 11:05 AM, revealed an unauthorized 3-way outlet multiplier was being utilized in the second floor break room number 2019.

Interview with maintenance director on January 3, 2011, at 11:05 AM, confirmed the unauthorized use of the outlet multiplier.

B. Observation on January 3, 2011, between 11:10 AM and 11:45 AM, revealed the following patient rooms had beds placed against electrical receptacles:

1. 11:10 AM - Second floor, Patient room 2020.

2. 11:45 - First floor, Patient room 1017.

Interview with maintenance director on January 3, 2010, at 11:46 AM, confirmed these beds were in contact with electrical receptacles.

Based on observation and interview it was determined the facility failed to provide electrical wiring and equipment in accordance with NFPA 101, and the National Electrical Code, NFPA 70 on two of two levels in this component.

Findings include:

A. Observation of electrical wiring and equipment on January 04, 2011, between 8:50 AM and 1:25 PM revealed the following:

1. 8:50 AM - Second floor resident room #2022 had a bed placed against a wall electrical receptacle.

2. 1:25 PM - First floor Central Supply break room had a microwave, toaster, and coffee pot plugged into a surge suppressor power strip.

Interview with Safety Manager on January 04, 2011, at 1:26 PM confirmed these electrical conditions.