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1001 STERIGERE STREET

NORRISTOWN, PA 19401

No Description Available

Tag No.: K0011

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.

No Description Available

Tag No.: K0012

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.

No Description Available

Tag No.: K0012

Based on observation and interview, it was determined that the facility failed to maintain the fire resisitve rating for building construction in one instance within this component.

Findings include:

Observation made on March 27, 2012, at 11:00 a.m., revealed that inside the janitors' closet AF wing, there was a ceiling tile missing from the rated ceiling assembly.

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 incomplete rated ceiling assembly.

No Description Available

Tag No.: K0017

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.

No Description Available

Tag No.: K0017

Based upon observation and interview, it was determined that the facility failed to ensure that the corridor walls form a barrier to limit the transfer of smoke on two of three levels in the component.

Findings include:

Observation on March 26, 2012, at 1:45 p.m., revealed that in Rooms 198 and 197, there were transfer grills utilized as return air from the rooms out into and above the corridor's monolithic ceiling. The interstitial space above the corridor ceiling is used as a return air plenum back to an air handler unit. The Facility shall verify the operation of the return air plenum in the corridor ceiling interstitial space, as it relates to limiting the transfer of smoke from room to room through the corridor. The facility shall also verify that the components located in the corridor ceiling's interstitial space are rated for use in a return air plenum.

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 corridor ceilings were used to transfer air from rooms to the corridor.

No Description Available

Tag No.: K0017

Based upon observation and interview, it was determined that the facility failed to ensure that the fire resistive rating of corridor walls was maintained for non-sprinklered buildings on one of two levels within this component.

Findings include:

Observation made on March 27, 2012, at 10:50 a.m., revealed that inside the Med room marked #142, AF wing, there was an unsealed penetration through the corridor wall for conduit.

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 was an unsealed penetration in the corridor wall at the above location.

No Description Available

Tag No.: K0018

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.

No Description Available

Tag No.: K0018

Based on observation and interview, it was determined that the facility failed to ensure that corridor doors are solid core and positively latching into the frame without impediments on one of two levels with in this component.

Findings include:

1. Observation made on March 26, 2012, at 2:40 p.m., revealed that on the first floor, AR wing, the Day room corridor door was held open by an unapproved device (two chairs); the door is equipped with a self-closer.

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 above corridor door was held open by unapproved devices.


2. Observation on March 27, 2012, at 9:55 a.m., revealed the corridor door would not close with enough force to positively latch the door into the frame at maintence/electrical room 049.

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 corridor door requires adjustment.


3. Observation made on March 27, 2012, at 10:45 a.m., revealed that the corridor door for Room #142 (med room) was not smoke tight in the frame.

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 above corridor door was not smoke tight.


4. Observation on March 27, 2012, at 10:50 a.m., in the CR wing, revealed that there was a transfer grille installed in the corridor door for pantry room 1036.

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 transfer grille in the corridor door.


5. Observation made on March 27, 2012, at 10:55 a.m., revealed that the corridor door for the AF Day room was held open by an unapproved device (a trash can).

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 above corridor door was obstructed from closing.


6. Observation on March 27, 2012, at 11:20 a.m., in the CF wing, revealed that the day room corridor door was held open with a large trash receptacle.

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 corridor door was held open by an unauthorized means.

No Description Available

Tag No.: K0018

Based on observation and interview, it was determined the facility failed ensure there were no impediments to the closing of the corridor doors, and ensure the corridor doors positively latch into the door frame on two of three levels within this component.

Findings include:

1. Observation on March 26, 2012, at 1:40 pm, on the first floor revealed the self-closure on locker room corridor door 199 failed to close the door with enough force to positively latch the door to the frame.

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 closure required adjustment.


2. Observation made on March 26, 2012, between 10:15 a.m. and 1:50 p.m., revealed that the following corridor doors were held open by an unapproved device.

a. 10:15 a.m., Ground floor corridor door to the dining room serving area was held open by an unapproved device (a wet floor sign); and
b. 1:50 p.m., the first floor corridor door from the Sally-port into the doctors exam area was held open by an unapproved device (table).

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 above doors had impediments to closing.


3. Observation made on March 26, 2012, at 11:50 a.m., revealed that the corridor door for Room #108, failed to positively latch into the frame. The door is equipped with a self-closer.

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 above doors failed to positively latch into the frame.

No Description Available

Tag No.: K0020

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.

No Description Available

Tag No.: K0020

Based upon observation and interview, it was determined that the facility failed to maintain the fire resistive rating of vertical openings between floors in one instance within this component.

Findings include:

Observation made on March 27, 2012, at 10:20 a.m., revealed that inside pipe-chase marked room #186 in the rear by the laundry chute # 2 there were two unsealed penetrations through the floor slab for piping.

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 through the floor slab.

No Description Available

Tag No.: K0020

Based on observation and interview, it was determined that the facility failed to maintain the fire resisitive rating of vertical openings in two instances within this component.

Findings include:

1. Observation made on March 26, 2012, at 10:59 a.m., revealed that on the first floor C-wing inside pipe chase #1115 which is across from the nurses station, there were penetrations of the shaft wall by a pipe and a large vertical crack of the wall above the door frame.

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 of the shaft wall.


2. Observations made on March 26 , 2012, between 11:02 and 11:25 a.m., revealed penetrations of the shaft walls which were sealed with spray on non-rated fire proofing materials in the following locations:

a. 11:02 a.m., first floor C-wing , inside pipe chase #1126 ductwork penetration of the shaft wall; and
b. 11:25 a.m., second floor C-wing, inside pipe chase # 2085 penetrations on the corridor wall of the 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 penetrations of the shaft wall.

No Description Available

Tag No.: K0025

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.

No Description Available

Tag No.: K0025

Based upon observation and interview, it was determined that the facility failed to maintain the fire resistance rating of the smoke barrier walls in four instances within this component.

Findings include:

Observations on March 27, 2012, between 11:00 and 11:40 a.m., revealed that there are unsealed penetrations of the smoke barrier walls in the following locations:

a. 11:00 a.m., first floor CR wing, above door 1031, wire, conduit, and duct penetrations;
b. 11:02 a.m., first floor CR wing, inside the pipe chase, unsealed penetrations of the bathroom pipes;
c. 11:05 a.m., first floor CR wing, between door labeled 1031 and 1072, wire and conduit penetrations; and
d. 11:40 a.m., first floor C wing, above door 1022, numerous unsealed penetrations and some wire pipe penetrations sealed with foam insulation spray.

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.

No Description Available

Tag No.: K0027

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.

No Description Available

Tag No.: K0029

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.

No Description Available

Tag No.: K0029

Based on observation and interview, it was determined that the facility failed to maintain a one hour fire resistive rated enclosure for hazardous areas on one of three levels within this component.

Findings include:

1. Observations on March 26, 2012, between 10:40 and 11:00 a.m., revealed that the storage room, which are greater than 50 square feet in area and contained numerous combustible materials, doors lack fire resistive ratings (FRR) and self closing devices in the the following locations:

a. 10:40 a.m., the second floor medical records supply, containing cardboard boxes, several boxes, and papers stored in open shelves; and
b. 11:00 a.m., second floor office 2351, numerous cardboard boxes, paper office supplies, and cardboard boxes containing foam cups.

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 storage room doors lacked an FRR and self closure.


2. Observations on March 26, 2012, between 10:40 and 11:00 a.m., revealed that the fire resistive rating was undetermined for the following storage rooms:

a. 10:40 a.m., second floor medical records supply, containing cardboard boxes, several boxes, and papers stored on open shelves; and
b. 11:00 a.m., second floor office 2351, numerous cardboard boxes, paper office supplies, and cardboard boxes containing foam cups.

The Facility Representatives shall verify that the above storage room partitions are constructed with at least a one hour fire resistive rated construction.

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 storage room doors lacked an FRR and self closure.

No Description Available

Tag No.: K0029

Based on observation and interview, it was determined that the facility failed to ensure that hazardous areas maintain a one hour enclosure in non-sprinklerered areas in two instances within this component.
Findings include:
1. Observation made on March 26, 2012 , at 1:35 p.m., revealed that the storage room door on the second floor C-wing, failed to positively latch when tested. The door has a self closure 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 failed to latch.


2. Observation made on March 26, 2012 at 2:04 p.m., revealed that in the second floor C-wing, the soiled linen room corridor door lacks a self closure. The soiled linen room also contains the linen chute.

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 lacks a self closure.

No Description Available

Tag No.: K0034

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.

No Description Available

Tag No.: K0038

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.

No Description Available

Tag No.: K0047

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.

No Description Available

Tag No.: K0047

Based upon observation and interview, it was determined that the facility failed to maintain clearly displya exit signs in two instances within this component.

Findings include:

Observation on March 26, 2012, at 1:40 p.m., revealed the exit sign near door 2040 has faded letterings.
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 exit sign was not clearly visible.

No Description Available

Tag No.: K0047

Based upon observation and interview, it was determined that the facility failed to maintain illumination of directional exit signs and directional arrows in three instances within this component.

Findings include:
1. Observation on March 26, 2012 between 9:44 and 11:55 a.m., revealed that the following locations have exit signs which lack illumination:
a. 9:44 a.m., first floor near door 1071; andb. 11:55 a.m., basement pharmacy.
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 illulminated exit signs were inoperable.

2. Observation on March 26, 2012, at 10:42 a.m., revealed that the second floor " B " section exit sign lacks a directional arrow toward the nearby exit stairway.
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 directional indicator.

No Description Available

Tag No.: K0052

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.

No Description Available

Tag No.: K0067

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.

No Description Available

Tag No.: K0067

Based upon observation and interview, it was determined that the facility failed to maintain inspection and testing of ductwork components within this building component.

Findings include:

Observation made on March 27, 2012, at 11:20 a.m., revealed that the facility could not verify or produce documentation verifying inspection and testing of fusible link fire dampers every four years.

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 documentation was unavailable.

No Description Available

Tag No.: K0067

Based on observation and interview, it was determined that the facility failed to ensure that the heating, ventilation, and air conditioning systems maintained in one instance within this component.

Findings include:

1. Observation made on March 26 , 2012 , at 10:34 a.m., revealed that in the first floor C -wing, inside pipe chase room # 1100, there was a duct that had a rectangular cut out.

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 cutout in the ductwork.

No Description Available

Tag No.: K0071

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.

No Description Available

Tag No.: K0071

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

Findings include:

1. Observation on March 26, 2012, at 3:02 p.m., revealed that the self-closing laundry chute termination door would not positively latch to the door assembly when released from the hold open chain and fusible link.

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 termination door failed to close properly.


2. Observation on March 26, 2012, at 3:05 p.m., revealed that the laundry chute termination room's fire rated corridor door was held open with a chock.

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 termination room door was held open with an unauthorized device.

No Description Available

Tag No.: K0144

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.

No Description Available

Tag No.: K0144

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 1:30 p.m., revealed that 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.

No Description Available

Tag No.: K0144

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

Findings include:
Observation on March 26, 2012, at 9:30 a.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.

No Description Available

Tag No.: K0147

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.

No Description Available

Tag No.: K0147

Based on observation and interview, it was determined the facility failed to ensure that all electrical circuit panelboard cabinets had all circuits legibly identified on three levels within this component.

Findings include:

Observations on March 26, 2012, between 10:20 and 10:35 a.m., revealed that the circuit directories were missing from the following electrical panelboard cabinets:

a. 10:20 a.m., C-2 wing, inside the laundry chute room; and
b. 10:35 a.m., C-2 wing front corridor, Panel cabinet labeled 2G-D.G.S.-1985.

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 circuit directories.

No Description Available

Tag No.: K0147

Based upon observation and interview, it was determined the facility failed to ensure all electrical equipment's protective plates and covers are secured in six instances within this component.

Findings include:

1. Observation on March 26, 2012, at 3:00 a.m., in the basement revealed inside elevator control room 024, the elevator control equipment protective panels were removed and sitting on the floor which exposed the electrical components and wiring.

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 elevator protective panels were missing.


2. Observation made on March 26, 2012, at 2:30 p.m., revealed that in the penthouse near the Honeywell controls, there was an electrical junction box that was missing its protective cover plate.

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 above electrical junction box that was missing its protective cover plate.


3. Observation on March 27, 2012, at 9:50 a.m., in the basement revealed inside elevator 9-B's control room, the elevator control equipment's protective panels were removed and sitting on the floor which exposed the electrical components and wiring.

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 elevator protective panels were missing.


4. Observation on March 27, 2012, at 11:15 a.m., revealed that the end compartment of the AF wing had wall mounted night-lights that were not secured to the walls at the following A,C, and H bays.

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 above electrical devices were not secured.

No Description Available

Tag No.: K0147

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

Findings include:

1. Observations made on March 26, 2012, between 9:34 and 11:25 a.m., revealed that there were open junction boxes and missing circuit breaker blank covers in the following locations:

a. 9:34 a.m., basement level mechanical room, small electrical panel next to a larger panel labeled P-2, 120/208 - Five are missing circuit breaker blank covers;
b. 10:25 a.m., first floor C-wing mechanical room #1094 - large open junction box at the ceiling between the corridor wall and the rear wall space;
c. 10:48 a.m., first floor C-wing inside pipe chase room #1144 - open junction box near the ground behind a pipe;
d. 11:12 a.m., penthouse elevator equipment room - open junction box; and
e. 11:25 a.m., second floor C-wing inside pipe chase room # 2085 - open junction box on the corridor 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 missing protective plates and circuit breaker blanks in the above named locations.


2. Observation made on March 26, 2012, at 9:50 a.m., revealed that in the basement level electrical vault room, there were three penetrations of the vault wall by a pipe, a circular cutout, and small drill holes in the 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 of the electrical vault room.


3. Observation made on March 26, 2012 at 10:40 a.m., revealed that in the first floor C-wing inside room # 1113 above the ceiling, there was were grey abandoned wires dangling from above the ductwork.

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 abandoned wires.


4. Observation made on March 26, 2012, at 11:28 a.m., revealed that on the second floor C-wing, inside the Dinette room # 10-C-2, a microwave oven has a power cord that is damaged and frayed were the cord meets the plug.

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 damaged cord.

No Description Available

Tag No.: K0147

Based on observation and interview, it was determined that the facility failed to prohibit unauthorized use of electrical devices and protect electrical wiring in two instances within this component.
Findings include:
1. Observation made on March 26, 2012 , at 1:55 p.m., revealed that in the second floor C-wing inside office #2116, a microwave oven and a refrigerator were powered by a powerstrip.
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 unauthorized use of the powerstrip.


2. Observation made on March 26, 2012, at 2:21 p.m., revealed that in the first floor C-wing inside pipe chase # 1088 there was an open junction box on the corridor side wall of the pipe chase.

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.