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Based upon observation and interview, it was determined that the facility failed to maintain the two hour fire resistance rating of the common wall separation on one of three levels within this component.

Findings include:

Observation made on March 26, 2012, at 9:50 a.m., revealed that there was an unsealed penetration for conduit (above and to the left of the exit sign) of the commonwall building separation into the tunnel above the door.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the above unsealed penetration.

Based on observation and interview, it was determined that the facility failed to ensure
the fire resistive rating of the building construction in two instances within this component.

Findings include:

Observations made on March 27, 2012 between 11:39 and 11:41 a.m., revealed that on the ground floor of C-wing there were holes of the monolithic ceilings that exposed the structural floor joists in the following locations:

a. 11:39 a.m., ground floor C-wing exit door #1042, inside the exit stairway; and
b. 11:41 a.m., ground floor C-wing corridor ceiling, across from the exit stairway door.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the holes in the ceilings.

Based upon observation and interview, it was determined that the facility failed to maintain the fire resistance rating of corridor walls in a non-sprinklered building in four instances within this component.

Findings include:
1. Observations made on March 26 , 2012, between 10:10 a.m. and 2:35 p.m., revealed that there were penetrations on the corridor walls in the following locations:

a. 10:10 a.m., ground floor corridor wall above the door for Room # 083, there was an unsealed penetration;
b. 2:08 p.m., second floor C-wing , inside mechanical Room #2103, above the ceiling, there was a penetration of the corridor cinder-block wall by a white data cable; and
c. 2:25 p.m., first floor C-wing , inside Room #1107, above the ceiling, there were three penetrations of the corridor cinder-block wall.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the penetrations on the corridor walls in the above named locations.


2. Observation on May 26, 2012, at 1:46 p.m., revealed there is an unsealed cable wire penetration of the corridor wall above door 2012.
Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the unsealed wall penetration.

Based upon observation and interview, it was determined that the facility failed to prevent any impediment to the closing of corridor in one instance within this component.

Findings include
Observation on March 26, 2012, at 10:48 a.m., revealed that the second floor dining area corridor door was held open with chair.
Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed that a chair was blocking open the dining area corridor door.

Based on observation and interview, it was determined that the facility failed to ensure that shafts walls and vertical openings are properly inspected and maintained to ensure their fire resistive rating on three of three of three levels within this facility.

Findings include:

Observation made on March 26, 2012, between 10:50 and 11:20 a.m., revealed that the facility failed to maintain the fire resistive rating of vertical openings between floors in the following locations:

a. 10:52 a.m., Room # 0121 is an open 3-story shaft bottom. This room's corridor door is equipped with a self-closer that was disconnected and fails to automatically close;
b. 11:05 a.m., Room # 079 is a 3-story shaft bottom and the corridor wall is part of the shaft and had three unsealed penetrations for conduit and wiring; and

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the failure to maintain the fire resistance rating of the vertical openings between floors.

Based upon observation and interview, it was determined that the facility failed to maintain the 1/2 hour fire resistance rating of the smoke barrier walls on three of three levels within this component.

Findings include:

1. Observation made on March 26, 2012, betweem 10:21 a.m. and 1:50 p.m., revealed that there were penetrations in the smoke barrier wall which were sealed with non rated material (yellow spray in foam insulation) in the following areas:

a. 10:21 a.m., second floor C-2 wing, above the door labeled 2004;
b. 10:45 a.m., second floor, above the door labeled 265;
c. 11:10 a.m., second floor above the door labeled 244;
d. 11:40 a.m., first floor, above the door labeled 135; and
e. 1:50 p.m., first floor, above the door labeled 1014.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed that there were penetrations which were improperly sealed.


2. Observations on March 26, 2012, between 11:20 am and 1:25 p.m., revealed there were unsealed penetrations of the smoke barrier walls in the following locations:

a. 10:35 a.m., ground floor above the smoke barrier doors marked #054, there were two unsealed penetrations for wiring;
b. 10:45 a.m., ground floor inside Room # 0082 in the nursing storage room, there were two unsealed penetrations for conduit in the smoke barrier wall and data wire;
c. 11:20 a.m., second floor, above door labeled 247, red and white wire penetration;
d. 11:30 a.m., first floor, above the entrance door into A-1 wing, wire penetrations;
e. 12:00 p.m., first floor, above the door labeled 179, red and white wire penetrations; and
f. 1:25 p.m., first floor, above door labeled 195, open conduit penetration and white wire penetration.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the unsealed penetrations of the smoke barriers.

Based upon observation and interview, it was determined that the facility failed to maintain smoke barrier door assemblies with smoke tight resistance on two of three levels within this facility.

Findings include:

Observation made on March 26, 2012, between 10:35 a.m. and 2:00 p.m., revealed that the following smoke barrier doors failed to fully close within the door frame:

a. 10:35 a.m., ground floor smoke barrier doors marked # 054 with coordination failed to fully close and latch; and
b. 2:00 p.m., first floor smoke barrier door marked #1033 failed to fully close and latch.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the smoke barrier doors failed to fully close.

Based on observation and interview, it was determined that the facility failed to ensure the doors to hazardous areas maintain a one hour enclosure on one of two levels within this component.

Findings include:

Observations on March 26, 2012, between 2:50 and 2:53 p.m., revealed that the fire resistive rated labels were missing or painted over on the following storage room corridor doors:

a. 2:50 p.m., basement nursing storage Room 016, door FRR label painted over; and
b. 2:53 p.m., basement records storage room, missing FRR label.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the missing or covered door labels.

Based upon observation and interview, it was determined that the facility failed to maintain the exit stairway walls in one instance within this component.

Findings include
Observation on March 26, 2012 at 10:31 a.m., revealed that there were unsealed insulated steam line penetrations in the first floor of Stairway S3-1.
Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the unsealed penetrations.

Based on observation and interview, it was determined that the facility failed to ensure that exit access is readily available at all times in one instance within this component.

Findings include:

Observation made on March 26, 2012 , at 9:57 a.m. , revealed that at the exterior loading dock area the exit discharge double doors were obstructed by laundry carts.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the obstructed exit doors and the subsequent correction of the deficiency made during the time of the survey.

Based upon observation and interview, it was determined that the facility failed to provide directional exit signs leading to an exit discharge in one instance within this component.

Findings include:

Observation on March 27, 2012, at 11:20 a.m., revealed that the main dining area has exit signs on the north and south sides of the room which lead into closed courtyards.
Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed exit signs do not lead to an area of refuge.

Based upon documentation review and interview, it was determined the facility failed to ensure that the fire alarm system components were maintained in operable condition one instance within this component.

Findings include:

Documentation reviewed on March 27, 2012, at 10:35 a.m., on the first floor in CR wing (long dorm) revealed that during a facility-initiated fire alarm test, a fire alarm strobe failed to function.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed that the strobe did not illuminate when tested.

Based on observation, documentation review, and interview, it was determined that the facility failed to provide protection of ductwork penetrations, maintain shaft enclosures, and inspect/test fire dampers within this component.

Findings include:

1. Observation made on March 26, 2012, at 10:45 am, revealed that ductwork penetrations lack fire dampers inside room # 0082 (nurses storage room). Ductwork passes through a five-foot by three-foot Room #0121 which is the bottom of an open 3-story shaft.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the that fire dampers were not installed.


2. Observation made on March 26, 2012, between 10:45 am and 10:50 am, revealed that the bottom of the 3-story shaft is open to storage areas:

a. 10:45 a.m., storage room # 0121 and 0082; and
b. 10:50 a.m., storage room # 0121.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed that the duct shaft was used for storage.


3. Observation made on March 26, 2012, at 11:20 am, revealed room #079 located at the bottom of the 3-story shaft, fire damper (at the shaft/corridor wall) was blocked open with a large piece of cardboard.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed that the ductwork was obstructed.


4. Observation on March 26, 2012, at 1:45 p.m., revealed on the first floor above the corridor ceiling at Rooms 197 and 198, the fire damper, damper track, and fusible links were completely covered with dirt. The fire dampers were located within the corridor wall and were installed in plenum air return system.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed that the fire damper was excessively dirty.


5. Review of documentation on March 27, 2012, at 2:00 p.m., revealed that there documentation was unavailable verifying fire dampers were inspected and serviced every four years as required.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed that the documentation was unavailable.

Based on observation and interview, it was determined that the facility failed to maintain the fire resistive rating for linen chutes on two of three levels within this component.

Findings include:

1. Observation on March 26, 2012, at 10:20 a.m., revealed that the second floor corridor door to the linen chute service opening room did not have a self-closing device installed.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed that the door lacked a closing device.


2. Observation on March 26, 2012, at 10:30 a.m., revealed that in ground floor linen chute termination room, the chute discharge door failed positively latch.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed that the chute discharge door failed to positively latch.

Based upon observation and interview, it was determined that the facility failed to provide a remote annunciator for the emergency generator in a location observed by operating personnel at a regular work station

Findings include
Observation on March 26, 2012, at 1:50 p.m., revealed the primary emergency generator lacks a remote annunciator panel.
Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the lack of a remote annunciator.

Based on observation and interview, it was determined that the facility failed to ensure that the electrical wiring is protected in two instances within this component.

Findings include:

1. Observation made on March 27, 2012 , at 11:29 a.m., revealed that on the ground floor of B-wing , above the doorway to Room # 1083 on the corridor side, there was an electrical conduit that had exposed wires dangling from it.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the exposed wires.


2. Observation made on March 27, 2012, at 11:36 a.m., revealed that on the ground floor of C-wing inside Room # 1062 above the doorway, there was a open electrical junction box that was missing its protective plate. The junction box was attached to Armor cable.

Interview at the exit conference with the Chief Executive Officer, Chief Operating Officer, Chief Nurse Executive, Director of Maintenance, Fire Marshall, and Safety Manager, on March 27, 2012, at 3:00 p.m., confirmed the open junction box.