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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with and smoke detection in spaces that are open to the corridor. This deficiency occurred in 2 of the 19 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.FINDINGS INCLUDE
1. On 4/30/14 at 9:42 am surveyor observed in the F1 smoke compartment on the First floor in the ED Registration, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. This observed situation was not compliant with NFPA 101 (2000 edition) 19.3.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (plant operations mechanic) and staff B (chief quality officer).2. On 4/30/14 at 11:05 am surveyor observed in the F2 smoke compartment on the Second floor in the Report Room, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. This observed situation was not compliant with NFPA 101 (2000 edition) 19.3.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with the plant operations mechanic) and the chief quality officer.

Based on observation and interview, the facility failed to separate two spaces from corridor, nor meet the smoke detection and sprinkler protection requirements in accordance with NFPA 101 19.3.6.1, 19.3.6.2.2. This deficient practice affected 2 of 19 smoke compartments in the non-patient sleeping areas of the facility.

Findings include

Item 1. During a tour of the facility with Staff B (chief quality officer), Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 3:42 pm that the computer training space located on the 1st Floor across the south stairwell #3 was open to corridor and not separated by at least a 1/2-hr fire-rated corridor wall, nor was the smoke detection and sprinkler/furniture and furnishing flame spread requirements for an existing construction stated in the Exception No. 6 (a) and (b) of NFPA 101 19.3.6.1 were met. The open space does not have a smoke detection and sprinkler system protection.

Item 2. During a tour of the facility with Staff B (chief quality officer), Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 3:55 pm that the 1st Floor old Med Surge Nurse Station of the 1963 building was open to corridor and not separated by at least a 1/2-hr fire-rated corridor wall, nor was the smoke detection and sprinkler/furniture and furnishing flame spread requirements for an existing construction stated in the Exception No. 6 (a) and (b) of NFPA 101 19.3.6.1 were met. The open space does not have a smoke detection and sprinkler system protection.

The above deficient situation was verified by a concurrent observation and interview with the plant operations director, chief quality officer, and the quality resources supervisor at the time of discovery, and also confirmed with Staff D (chief executive officer) at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent. This deficiency occurred in 1 of the 19 smoke compartments in the facility, and had the potential to affect an undetermined number of staff and visitors.FINDINGS INCLUDE:On 4/30/14 at 10:37 am surveyor observed in the F2 smoke compartment on the Second floor in the Corridor, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near exit signs need to be corrected. One exit light needs to be added and another exit light leads to a corridor that is not an exit. This observed situation was not compliant with NFPA 101 (2000 edition) 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (plant operations mechanic) and staff I (quality resources supervisor).

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to exit signs to reach an exit not properly installed in 2 locations in accordance with NFPA 101 7.10.1.4. This deficient practice affected 2 of 19 smoke compartments in the facility.

Findings include

Item 1. During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 4:25 pm that the exit sign at the south end corner of corridor in the Sleep Lab on the 1st Floor did not have a Chevron arrow pointing to the exit access corridor that leads to exit. The exit sign was installed near and above the exit access double doors of the outpatient medical clinic suite and indicated access to an exit through the suite, and not toward the exit access corridor leading to an exit. The suite was previously used as an ICU suite.

Item 2. During a tour of the facility with the director of plant operations), and Staff M3 (plant operations mechanic) on 4/30/14, surveyor observed at 10:35 am that the exit sign installed in the Stairwell #4 on the 1st Floor level did not point to the right direction for exiting the stairwell at the ground floor level due to lack of a Chevron arrow in the sign.


The above deficiency was acknowledged by the plant operations director, the plant operations mechanic at the time of discovery, and confirmed with Staff D (chief executive officer) and the quality resources supervisor at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency occurred in 1 of the 19 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.FINDINGS INCLUDE
On 4/30/14 at 9:12 am surveyor observed in the F1 smoke compartment on the First floor in the Corridor, that penetration(s) were not sealed according to according to an approved method. The deficiency included pipes through the wall, above the double doors, that were not sealed at the wall. This observed situation was not compliant with NFPA 101 (2000 edition) 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (plant operations mechanic) and staff B (chief quality officer).

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to penetrations of 1-hr fire/smoke barriers in numerous locations that were not sealed in accordance with NFPA 101 19.3.7.3. This deficient practice affected 1 of 19 smoke compartments in the facility.

Findings include

Item 1. During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 11:15 am that three 3 " dia. pipe penetrations were not sealed around the pipe, and one 3 inch x 8 inch rectangular void space at the top joint of the 1-hr fire/smoke barrier was not filled in to provide at least a 1/2 hour fire resistance rating. The smoke barrier wall constitutes one of the enclosing 1-hr fire barrier walls of the electrical service mains room 128 located on the ground floor;

Item 2. During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 11:35 am that one 1 ? " dia. cable penetration of smoke barrier wall above double smoke doors was not sealed properly. The smoke doors were located across Womens ' locker room on the ground floor;

Item 3. During a tour of the facility with the quality resources supervisor, the director of plant operations, and the plant operations mechanic on 4/29/14, surveyors observed at 11:52 am that one conduit/cable penetration of, and one duct opening in the 2-hr fire/smoke barrier wall above double smoke doors were not properly sealed properly. The smoke doors in the 2-hr fire/smoke barrier between the 2010 New addition and the 1990 building were located in Corridor 1009 near the elevator lobby on the ground floor; and

Item 4. While on a tour with the director of plant operations, and Staff M3 (plant operations mechanic) on 4/30/14, surveyors observed at 10:42 am that one 1 ? " dia. cable penetration of 2-hr fire-rated fire/smoke barrier wall above double smoke doors was not properly sealed. The cross-corridor smoke doors were located adjacent to the Center Stairwell #4 on the ground floor.

The above deficiency was acknowledged by the plant operations director, the quality resources supervisor, and the plant operations mechanic at the time of discovery, and confirmed with Staff D (chief executive officer) at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to lack of properly fire-rated vision panel in one smoke door in accordance with the requirement of NFPA 101 19.3.7.5. This deficient practice affected 1 of 19 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 11:30 am that the vision panel of the single leaf smoke barrier door adjacent to the bank of elevators in the 1963 building on the ground floor was neither a 20-minute fire rated glazing material, nor a fixed wire meshed glass.

The above deficiency was acknowledged by the quality resources supervisor, the plant operations director, and the plant operations mechanic at the time of discovery, and confirmed with Staff D (chief executive officer) at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility failed to enclose hazardous areas with a properly installed fire-rated walls and self-closing doors in accordance with NFPA 101 19.3.2.1. This deficient practice affected 3 of 19 smoke compartments in the non-patient sleeping areas of the facility.

Findings include

Item 1. During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 12:12 pm that (i) one of four walls enclosing the Storage Room 192 was damaged resulting in a 4 " x 4 " hole at a location where the door knob of exit access door hit the wall, when the door was in fully open position; and (ii) several drywall screw heads were not mudded and taped over on the wall in accordance with the UL design for installation of a 1-hr fire resistance rated fire barrier wall.

Item 2. During a tour of the facility with Staff B (chief quality officer), the quality resources supervisor, the director of plant operations, and the plant operations mechanic on 4/29/14, surveyors observed at 1:45 am that the Storage Room 174 adjacent to the current cardiac rehab room on the ground floor did not have a self-closing device in accordance with 19.3.2.1, 8.4, 8.2.4.3.1. The storage room was previously a cardiac rehab room. The room is fully sprinkler protected.

Item 3. During a tour of the facility with the quality resources supervisor, the director of plant operations, and Staff M3 (plant operations mechanic) on 4/30/14, surveyor observed at 3:50 pm that the old patient Room 103 on the first floor south wing was now used as a storage, but did not have a self-closing device on the corridor door for a sprinkler protected room/space in accordance with 19.3.2.1, 8.4, 8.2.4.3.1. The entire wing of the 1963 building is no longer a patient sleeping area.

The above deficient situation was verified by a concurrent observation and interview with the plant operations director, chief quality officer, and the quality resources supervisor at the time of discovery, and also confirmed with Staff D (chief executive officer) at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility did not provide egress paths at all times with travel interruption at stairs that go below the level of exit discharge. This deficiency occurred in 1 of the 19 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.FINDINGS INCLUDE
On 4/30/14 at 9:17 am surveyor observed in the F1 smoke compartment on the First floor in the Stair, that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge. No gate was provided to prevent people from exiting into the basement. This observed situation was not compliant with NFPA 101 (2000 edition) 7.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (plant operations mechanic) and staff B (chief quality officer).

Based on observation and interview, the facility failed to provide a fire alarm system that was installed to minimum standards of NFPA 72 in accordance with NFPA 9.6.1.4, 9.6.3.2. The deficient practice affected 3 of 19 smoke compartments in the non-patient sleeping areas of the facility.

Findings include

Item 1. While on a tour of the facility with Staff B (chief quality officer), Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 1:55 pm that the outpatient Cardiac Rehab Room 169 on the ground floor did not have a visual alarm notification appliance for occupant notification; and

Item 2. While on a tour of the facility with the director of plant operations, and Staff M3 (plant operations mechanic) on 4/30/14, surveyor observed between 8:50 am and 9:40 am that the Emergency Call Room 280 adjacent to the Pharmacy, the Cardio Pulmonary Rehab Room 2046 adjacent to the Urgent Care, and the Mens ' and Women ' s Locker Rooms 2052 and 2049 adjacent to the cardio pulmonary rehab on the first floor did not have visual alarm notification appliances for occupant notification;

The above deficient situation was verified by a concurrent observation and interview with the plant operations director at the time of discovery, and also confirmed with Staff D (chief executive officer) and the quality resources supervisor at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code Section 9.7.1.1 due to sprinkler heads of improper temperature ratings. This deficiency occurred in 1 of 19 smoke compartments, and had the potential to affect an undetermined number of patients, staff and visitors.FINDINGS INCLUDE
On 4/30/14 at 2:12 pm surveyors observed in the F2 smoke compartment on the Second floor in patient Rooms 2212 & 2214 that one sprinkler head in each room located at 16 inch from the slot type HVAC diffuser in the ceiling was of an intermediate temperature rating, and not of an ordinary temperature rating as required for sprinklers located more than 1 ft radius from the ceiling diffuser blowing downward. This observed situation was not compliant with NFPA 13 (1999 edition) 5-3.1.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (plant operations mechanic), staff I (quality resources supervisor) and staff M1 (director of plant operations).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have and sprinklers free of lint. This deficiency occurred in 2 of the 19 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.FINDINGS INCLUDE
1. On 4/30/14 at 10:50 am surveyor observed in the G2 smoke compartment on the Second floor in the Medication Prep, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition) 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (quality resources supervisor) and staff M4 (plant operations mechanic).2. On 4/30/14 at 10:59 am surveyor observed in the F2 smoke compartment on the Second floor in the Clean Utility, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition) 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with the plant operations mechanic and the quality resources supervisor.
3. On 4/30/14 at 1:38 pm surveyor observed in the F2 smoke compartment on the Second floor in the Nurse Station, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition) 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with the plant operations mechanic and the quality resources supervisor.

Based on observation and interview, the facility failed to ensure safety to patients and staff of the facility due to soiled linen receptacles not stored in a room protected as a hazardous area in accordance with NFPA 101 19.7.5.5. This deficient practice affected 1 of 19 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 4:28 pm that 2 personal laundry bags, and 1 trash receptacle of a combined capacity of more than 32 gal were stored in one room the exit access door of which did not have a self-closing device in accordance with 19.7.5.5, 19.3.2.1. The combined capacity of three containers exceeded the allowable density of 0.5 gal per sq ft of floor area. The room is located in the north end of the Sleep Lab on the first floor.

The above observed condition was verified by a concurrent observation and interview with the quality resources supervisor, the plant operations director, and the plant operations mechanic at the time of discovery, and confirmed with Staff D (chief executive officer) at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility failed to ensure safety to patients, and staff of the facility due to (i) ceiling of one room not properly maintained; (ii) one of two exits not readily operable in accordance with NFPA 101 7.2.1.5.4; and (iii) lack of manual fire alarm near the rear exit. This deficient practice affected all patients and staff in the clinic building.

Findings include

Item 1.
NFPA 25(1998) 1-11.1 "Maintenance shall be performed to keep the system equipment operable or to make repairs......."

During a tour of the facility with Staff I (quality resources supervisor), Staff X (director of rehab services), and Staff M5 (plant operations mechanic) on 5/01/14, surveyor observed at 9:05 am that the ceiling of one office room adjacent to the clinic entrance door was not properly maintained due to 2 " x 10 " and 2 " x 4 " holes in the ceiling. The holes in the ceiling would cause a delay in the activation of sprinkler heads in the space. This observed situation is not compliant with NFPA 25 91998) 1-11.1.

Item 2.
NFPA 101 7.2.1.5.4*
"A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation. "

While on a tour of the facility with the quality resources supervisor, the director of rehab services, and the plant operations mechanic on 5/01/14, surveyor observed at 9:13 am that the rear exit door had a dead bolt (thumb latch), which is not considered as an obvious method of operation to operate the door under all lighting conditions. The releasing mechanism to open the door also required more than one releasing operation. This observed situation is not compliant with NFPA 101 7.2.1.5.4.


Item 3.
NFPA 101 9.6.2.3
"A manual fire alarm box shall be provided in the natural exit access path near each required exit from an area, unless modified by another section of this Code. "

While on a tour of the facility with the quality resources supervisor, the director of rehab services, and the plant operations mechanic on 5/01/14, surveyor observed at 9:20 am that there was no manual fire alarm box installed near the rear exit out of the rehab clinic. This observed situation is not compliant with NFPA 101 9.6.2.3.

The above deficient condition was verified by a concurrent observation and interview with the quality resources supervisor, director of rehab services, and plant operations mechanic at the time of discovery. The deficient condition was also confirmed with Staff D (chief executive officer), and Staff (M1) at the time of exit conference on 5/01/14 at 12 pm.

Based on observation and staff interview, the facility failed to provide working space in front of electrical panel and equipment in two locations in accordance with NFPA 70 110-26. This affected 1 of 19 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 11:25 am that two chairs were stored directly below one automatic transfer switch, and one table and one chair were stored in front of an electrical panel in the Electrical Service Mains Room 128. The objects did not provide working space required in front of electrical panel and switches in accordance with NFPA 70 110-26. The electrical room is located in the ground floor.

The above deficiency was acknowledged by the quality resources supervisor, the plant operations director, and the plant operations mechanic at the time of survey, and confirmed with Staff D (chief executive officer) at the exit conference on 5/01/14 at 12 pm.

NFPA 70 110-26.
"Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment ... "

NFPA 70 110-26(b) Clear Spaces.
"Working space required by this section shall not be used for storage ..."

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with and smoke detection in spaces that are open to the corridor. This deficiency occurred in 2 of the 19 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.FINDINGS INCLUDE
1. On 4/30/14 at 9:42 am surveyor observed in the F1 smoke compartment on the First floor in the ED Registration, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. This observed situation was not compliant with NFPA 101 (2000 edition) 19.3.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (plant operations mechanic) and staff B (chief quality officer).2. On 4/30/14 at 11:05 am surveyor observed in the F2 smoke compartment on the Second floor in the Report Room, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. This observed situation was not compliant with NFPA 101 (2000 edition) 19.3.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with the plant operations mechanic) and the chief quality officer.

Based on observation and interview, the facility failed to separate two spaces from corridor, nor meet the smoke detection and sprinkler protection requirements in accordance with NFPA 101 19.3.6.1, 19.3.6.2.2. This deficient practice affected 2 of 19 smoke compartments in the non-patient sleeping areas of the facility.

Findings include

Item 1. During a tour of the facility with Staff B (chief quality officer), Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 3:42 pm that the computer training space located on the 1st Floor across the south stairwell #3 was open to corridor and not separated by at least a 1/2-hr fire-rated corridor wall, nor was the smoke detection and sprinkler/furniture and furnishing flame spread requirements for an existing construction stated in the Exception No. 6 (a) and (b) of NFPA 101 19.3.6.1 were met. The open space does not have a smoke detection and sprinkler system protection.

Item 2. During a tour of the facility with Staff B (chief quality officer), Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 3:55 pm that the 1st Floor old Med Surge Nurse Station of the 1963 building was open to corridor and not separated by at least a 1/2-hr fire-rated corridor wall, nor was the smoke detection and sprinkler/furniture and furnishing flame spread requirements for an existing construction stated in the Exception No. 6 (a) and (b) of NFPA 101 19.3.6.1 were met. The open space does not have a smoke detection and sprinkler system protection.

The above deficient situation was verified by a concurrent observation and interview with the plant operations director, chief quality officer, and the quality resources supervisor at the time of discovery, and also confirmed with Staff D (chief executive officer) at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent. This deficiency occurred in 1 of the 19 smoke compartments in the facility, and had the potential to affect an undetermined number of staff and visitors.FINDINGS INCLUDE:On 4/30/14 at 10:37 am surveyor observed in the F2 smoke compartment on the Second floor in the Corridor, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near exit signs need to be corrected. One exit light needs to be added and another exit light leads to a corridor that is not an exit. This observed situation was not compliant with NFPA 101 (2000 edition) 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (plant operations mechanic) and staff I (quality resources supervisor).

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to exit signs to reach an exit not properly installed in 2 locations in accordance with NFPA 101 7.10.1.4. This deficient practice affected 2 of 19 smoke compartments in the facility.

Findings include

Item 1. During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 4:25 pm that the exit sign at the south end corner of corridor in the Sleep Lab on the 1st Floor did not have a Chevron arrow pointing to the exit access corridor that leads to exit. The exit sign was installed near and above the exit access double doors of the outpatient medical clinic suite and indicated access to an exit through the suite, and not toward the exit access corridor leading to an exit. The suite was previously used as an ICU suite.

Item 2. During a tour of the facility with the director of plant operations), and Staff M3 (plant operations mechanic) on 4/30/14, surveyor observed at 10:35 am that the exit sign installed in the Stairwell #4 on the 1st Floor level did not point to the right direction for exiting the stairwell at the ground floor level due to lack of a Chevron arrow in the sign.


The above deficiency was acknowledged by the plant operations director, the plant operations mechanic at the time of discovery, and confirmed with Staff D (chief executive officer) and the quality resources supervisor at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency occurred in 1 of the 19 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.FINDINGS INCLUDE
On 4/30/14 at 9:12 am surveyor observed in the F1 smoke compartment on the First floor in the Corridor, that penetration(s) were not sealed according to according to an approved method. The deficiency included pipes through the wall, above the double doors, that were not sealed at the wall. This observed situation was not compliant with NFPA 101 (2000 edition) 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (plant operations mechanic) and staff B (chief quality officer).

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to penetrations of 1-hr fire/smoke barriers in numerous locations that were not sealed in accordance with NFPA 101 19.3.7.3. This deficient practice affected 1 of 19 smoke compartments in the facility.

Findings include

Item 1. During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 11:15 am that three 3 " dia. pipe penetrations were not sealed around the pipe, and one 3 inch x 8 inch rectangular void space at the top joint of the 1-hr fire/smoke barrier was not filled in to provide at least a 1/2 hour fire resistance rating. The smoke barrier wall constitutes one of the enclosing 1-hr fire barrier walls of the electrical service mains room 128 located on the ground floor;

Item 2. During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 11:35 am that one 1 ? " dia. cable penetration of smoke barrier wall above double smoke doors was not sealed properly. The smoke doors were located across Womens ' locker room on the ground floor;

Item 3. During a tour of the facility with the quality resources supervisor, the director of plant operations, and the plant operations mechanic on 4/29/14, surveyors observed at 11:52 am that one conduit/cable penetration of, and one duct opening in the 2-hr fire/smoke barrier wall above double smoke doors were not properly sealed properly. The smoke doors in the 2-hr fire/smoke barrier between the 2010 New addition and the 1990 building were located in Corridor 1009 near the elevator lobby on the ground floor; and

Item 4. While on a tour with the director of plant operations, and Staff M3 (plant operations mechanic) on 4/30/14, surveyors observed at 10:42 am that one 1 ? " dia. cable penetration of 2-hr fire-rated fire/smoke barrier wall above double smoke doors was not properly sealed. The cross-corridor smoke doors were located adjacent to the Center Stairwell #4 on the ground floor.

The above deficiency was acknowledged by the plant operations director, the quality resources supervisor, and the plant operations mechanic at the time of discovery, and confirmed with Staff D (chief executive officer) at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to lack of properly fire-rated vision panel in one smoke door in accordance with the requirement of NFPA 101 19.3.7.5. This deficient practice affected 1 of 19 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 11:30 am that the vision panel of the single leaf smoke barrier door adjacent to the bank of elevators in the 1963 building on the ground floor was neither a 20-minute fire rated glazing material, nor a fixed wire meshed glass.

The above deficiency was acknowledged by the quality resources supervisor, the plant operations director, and the plant operations mechanic at the time of discovery, and confirmed with Staff D (chief executive officer) at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility failed to enclose hazardous areas with a properly installed fire-rated walls and self-closing doors in accordance with NFPA 101 19.3.2.1. This deficient practice affected 3 of 19 smoke compartments in the non-patient sleeping areas of the facility.

Findings include

Item 1. During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 12:12 pm that (i) one of four walls enclosing the Storage Room 192 was damaged resulting in a 4 " x 4 " hole at a location where the door knob of exit access door hit the wall, when the door was in fully open position; and (ii) several drywall screw heads were not mudded and taped over on the wall in accordance with the UL design for installation of a 1-hr fire resistance rated fire barrier wall.

Item 2. During a tour of the facility with Staff B (chief quality officer), the quality resources supervisor, the director of plant operations, and the plant operations mechanic on 4/29/14, surveyors observed at 1:45 am that the Storage Room 174 adjacent to the current cardiac rehab room on the ground floor did not have a self-closing device in accordance with 19.3.2.1, 8.4, 8.2.4.3.1. The storage room was previously a cardiac rehab room. The room is fully sprinkler protected.

Item 3. During a tour of the facility with the quality resources supervisor, the director of plant operations, and Staff M3 (plant operations mechanic) on 4/30/14, surveyor observed at 3:50 pm that the old patient Room 103 on the first floor south wing was now used as a storage, but did not have a self-closing device on the corridor door for a sprinkler protected room/space in accordance with 19.3.2.1, 8.4, 8.2.4.3.1. The entire wing of the 1963 building is no longer a patient sleeping area.

The above deficient situation was verified by a concurrent observation and interview with the plant operations director, chief quality officer, and the quality resources supervisor at the time of discovery, and also confirmed with Staff D (chief executive officer) at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility did not provide egress paths at all times with travel interruption at stairs that go below the level of exit discharge. This deficiency occurred in 1 of the 19 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.FINDINGS INCLUDE
On 4/30/14 at 9:17 am surveyor observed in the F1 smoke compartment on the First floor in the Stair, that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge. No gate was provided to prevent people from exiting into the basement. This observed situation was not compliant with NFPA 101 (2000 edition) 7.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (plant operations mechanic) and staff B (chief quality officer).

Based on observation and interview, the facility failed to provide a fire alarm system that was installed to minimum standards of NFPA 72 in accordance with NFPA 9.6.1.4, 9.6.3.2. The deficient practice affected 3 of 19 smoke compartments in the non-patient sleeping areas of the facility.

Findings include

Item 1. While on a tour of the facility with Staff B (chief quality officer), Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 1:55 pm that the outpatient Cardiac Rehab Room 169 on the ground floor did not have a visual alarm notification appliance for occupant notification; and

Item 2. While on a tour of the facility with the director of plant operations, and Staff M3 (plant operations mechanic) on 4/30/14, surveyor observed between 8:50 am and 9:40 am that the Emergency Call Room 280 adjacent to the Pharmacy, the Cardio Pulmonary Rehab Room 2046 adjacent to the Urgent Care, and the Mens ' and Women ' s Locker Rooms 2052 and 2049 adjacent to the cardio pulmonary rehab on the first floor did not have visual alarm notification appliances for occupant notification;

The above deficient situation was verified by a concurrent observation and interview with the plant operations director at the time of discovery, and also confirmed with Staff D (chief executive officer) and the quality resources supervisor at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code Section 9.7.1.1 due to sprinkler heads of improper temperature ratings. This deficiency occurred in 1 of 19 smoke compartments, and had the potential to affect an undetermined number of patients, staff and visitors.FINDINGS INCLUDE
On 4/30/14 at 2:12 pm surveyors observed in the F2 smoke compartment on the Second floor in patient Rooms 2212 & 2214 that one sprinkler head in each room located at 16 inch from the slot type HVAC diffuser in the ceiling was of an intermediate temperature rating, and not of an ordinary temperature rating as required for sprinklers located more than 1 ft radius from the ceiling diffuser blowing downward. This observed situation was not compliant with NFPA 13 (1999 edition) 5-3.1.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M4 (plant operations mechanic), staff I (quality resources supervisor) and staff M1 (director of plant operations).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have and sprinklers free of lint. This deficiency occurred in 2 of the 19 smoke compartments, and had the potential to affect an undetermined number of staff and visitors.FINDINGS INCLUDE
1. On 4/30/14 at 10:50 am surveyor observed in the G2 smoke compartment on the Second floor in the Medication Prep, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition) 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (quality resources supervisor) and staff M4 (plant operations mechanic).2. On 4/30/14 at 10:59 am surveyor observed in the F2 smoke compartment on the Second floor in the Clean Utility, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition) 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with the plant operations mechanic and the quality resources supervisor.
3. On 4/30/14 at 1:38 pm surveyor observed in the F2 smoke compartment on the Second floor in the Nurse Station, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition) 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with the plant operations mechanic and the quality resources supervisor.

Based on observation and interview, the facility failed to ensure safety to patients and staff of the facility due to soiled linen receptacles not stored in a room protected as a hazardous area in accordance with NFPA 101 19.7.5.5. This deficient practice affected 1 of 19 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 4:28 pm that 2 personal laundry bags, and 1 trash receptacle of a combined capacity of more than 32 gal were stored in one room the exit access door of which did not have a self-closing device in accordance with 19.7.5.5, 19.3.2.1. The combined capacity of three containers exceeded the allowable density of 0.5 gal per sq ft of floor area. The room is located in the north end of the Sleep Lab on the first floor.

The above observed condition was verified by a concurrent observation and interview with the quality resources supervisor, the plant operations director, and the plant operations mechanic at the time of discovery, and confirmed with Staff D (chief executive officer) at the exit conference on 5/01/14 at 12 pm.

Based on observation and interview, the facility failed to ensure safety to patients, and staff of the facility due to (i) ceiling of one room not properly maintained; (ii) one of two exits not readily operable in accordance with NFPA 101 7.2.1.5.4; and (iii) lack of manual fire alarm near the rear exit. This deficient practice affected all patients and staff in the clinic building.

Findings include

Item 1.
NFPA 25(1998) 1-11.1 "Maintenance shall be performed to keep the system equipment operable or to make repairs......."

During a tour of the facility with Staff I (quality resources supervisor), Staff X (director of rehab services), and Staff M5 (plant operations mechanic) on 5/01/14, surveyor observed at 9:05 am that the ceiling of one office room adjacent to the clinic entrance door was not properly maintained due to 2 " x 10 " and 2 " x 4 " holes in the ceiling. The holes in the ceiling would cause a delay in the activation of sprinkler heads in the space. This observed situation is not compliant with NFPA 25 91998) 1-11.1.

Item 2.
NFPA 101 7.2.1.5.4*
"A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation. "

While on a tour of the facility with the quality resources supervisor, the director of rehab services, and the plant operations mechanic on 5/01/14, surveyor observed at 9:13 am that the rear exit door had a dead bolt (thumb latch), which is not considered as an obvious method of operation to operate the door under all lighting conditions. The releasing mechanism to open the door also required more than one releasing operation. This observed situation is not compliant with NFPA 101 7.2.1.5.4.


Item 3.
NFPA 101 9.6.2.3
"A manual fire alarm box shall be provided in the natural exit access path near each required exit from an area, unless modified by another section of this Code. "

While on a tour of the facility with the quality resources supervisor, the director of rehab services, and the plant operations mechanic on 5/01/14, surveyor observed at 9:20 am that there was no manual fire alarm box installed near the rear exit out of the rehab clinic. This observed situation is not compliant with NFPA 101 9.6.2.3.

The above deficient condition was verified by a concurrent observation and interview with the quality resources supervisor, director of rehab services, and plant operations mechanic at the time of discovery. The deficient condition was also confirmed with Staff D (chief executive officer), and Staff (M1) at the time of exit conference on 5/01/14 at 12 pm.

Based on observation and staff interview, the facility failed to provide working space in front of electrical panel and equipment in two locations in accordance with NFPA 70 110-26. This affected 1 of 19 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff I (quality resources supervisor), Staff M1 (director of plant operations), and Staff M2 (plant operations mechanic) on 4/29/14, surveyors observed at 11:25 am that two chairs were stored directly below one automatic transfer switch, and one table and one chair were stored in front of an electrical panel in the Electrical Service Mains Room 128. The objects did not provide working space required in front of electrical panel and switches in accordance with NFPA 70 110-26. The electrical room is located in the ground floor.

The above deficiency was acknowledged by the quality resources supervisor, the plant operations director, and the plant operations mechanic at the time of survey, and confirmed with Staff D (chief executive officer) at the exit conference on 5/01/14 at 12 pm.

NFPA 70 110-26.
"Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment ... "

NFPA 70 110-26(b) Clear Spaces.
"Working space required by this section shall not be used for storage ..."