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Based on observation and interview, the facility did not provide corridor separation doors with doors with positive-latching hardware, self-latching inactive doors, positive-latching hardware, smoke-tight seals at meeting edges, and doors that would close when pushed or pulled. This deficiency occurred in 3 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/12/2012 at 10:50 am, observation revealed on the lower level floor in the health information services Room 37, that the corridor door would not positively self-latch when pushed to a closed position. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.2.

2. On 11/12/2012 at 3:26 pm, observation revealed on the lower level floor in the dinning room, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it had manual latching hardware. The active leaf latched into the inactive leaf. If the inactive leaf would not positively latch, the entire door assembly would not remain closed when a force of 5 pounds is applied. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

3. On 11/13/2012 at 3:00 pm, observation revealed on the upper level floor in the room 150D decontamination (Surgery soiled Utility), that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

4. On 11/14/2012 at 11:30 am, observation revealed on the upper level floor in surgery, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.1.

5. On 11/14/2012 at 1:45 pm, observation revealed on the upper level floor in the laboratory, that the door to the corridor was held open with an electric hold open door operator. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.3.

6. On 11/12/2012 at 10:30 am surveyor observed on the lower level, that the corridor door to the procedure suite of the Speciality Clinic would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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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 2 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/12/2012 at 1:00 pm, observation revealed on the lower level floor in the dialysis equipment room, that penetration(s) were not sealed according to an approved method. The deficiency included 4 conduits above the ceiling, and 1 conduit at the ceiling line. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not enclose hazardous rooms with a closer on all doors, rated wall construction, sealed wall penetrations, sealed wall penetrations, and rated doors. This deficiency occurred in 4 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/12/2012 at 10:45 am, observation revealed on the lower level floor in the soiled utility room of the procedure room of the speciality clinic, that the door would not self-close because there was no closer on the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 and 18.3.6.3.4.

2. On 11/12/2012 at 10:45 am, observation revealed on the lower level floor in the soiled utility room of the procedure room of the speciality clinic, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had an electrical panel, (42" X 26") that exceeded the 100 square inches of electrical outlets in a 100 square feet of rated wall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

3. On 11/12/2012 at 10:45 am, observation revealed on the lower level floor in the soiled utility room of the procedure room of the speciality clinic, that penetration(s) were not sealed according to an approved method. The deficiency included holes in the rated wall above the ceiling tile. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

4. On 11/12/2012 at 1:20 pm, observation revealed on the lower level floor in the file room (medical records), that penetration(s) were not sealed according to according to an approved method. The deficiency included sewer or drain piping in the SW corner of the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

5. On 11/12/2012 at 2:15 pm, observation revealed on the lower level floor in the garage, that penetration(s) were not sealed according to according to an approved method. The deficiency included the wall not being sealed at the top of the wall to floor interface. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

6. On 11/12/2012 at 2:31 pm, observation revealed on the lower level floor in the Maintenance shop, that penetration(s) were not sealed according to according to an approved method. The deficiency included a polyvinyl chloride PVC pipe that did not have a fire rated collar on it at the south wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

7. On 11/12/2012 at 2:55 pm, observation revealed on the lower level floor in the Housekeeping room near the garage area, that penetration(s) were not sealed according to according to an approved method. The deficiency included a four inch diameter pipe that was not properly sealed to the floor above. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

8. On 11/13/2012 at 3:10 pm, observation revealed on the upper level floor in the room 150D decontamination (Surgery soiled Utility), that the fire barrier door could not be verified to have the required rating. The door was missing to the 'dirty processing area'. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide egress paths at all times with the required signage, and no obstructions in the path of egress. This deficiency occurred in 2 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/13/2012 at 8:20 am, observation revealed on the upper level floor in the storage room 235, that the exit path was not readily accessible because boxes and equipment blocked the door from opening to a fully open position. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

2. On 11/13/2012 at 9:00 am, observation revealed on the upper level floor the OBGYN cross corridor doors has a delayed egress lock (DEL) that did not have the required signage on the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.6.1.

3. On 11/13/2012 at 9:30 am, observation revealed on the upper level floor in the storage room 102, that the exit path was not readily accessible because boxes and equipment blocked the door from opening to a fully open position. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide and maintain emergency illumination of the emergency generator. This deficiency occurred in all of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/13/2012 at 11:00 am, observation revealed at the exterior of the building in the generator enclosure area, that a battery-operated emergency light was not installed in the interior emergency generator location. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.9.2.3, and NFPA 110 (1999 ed.), 5-3.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The facility did not provide a fire alarm system with compliant fire alarm. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/12/2012 at 11:15 am, observation revealed on the lower level floor in meeting Room 92, that the fire alarm installation was not compliant. A strobe for notification of the fire alarm system was missing in the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 1-5.2.5.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with all rooms sprinkled when the code required full sprinkling, sprinklers located the appropriate distance from the ceiling, unobstructed water distribution, matching response sensitivity, all rooms sprinkled when the code required full sprinkling, sprinklers free of obstructions near the ceiling, and all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 5 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/12/2012 at 1:40 pm, observation revealed on the lower level floor in the server room, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The room has a Novec 1230 fire suppression system that does not shut off the return/supply air from the air handler system. This observed situation was not compliant with NFPA 101 (2000 ed.).

2. On 11/12/2012 at 2:00 pm, observation revealed on the lower level floor in the material management system, that 4 sprinklers were located 27" below the obstructed ceiling. Sprinklers can be a maximum of 22" below an obstructed ceiling. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.4.1.1.

3. On 11/12/2012 at 2:03 pm, observation revealed on the lower level floor in the material management system, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included storage above the sprinkler level at the perimeter of the room. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

4. On 11/12/2012 at 2:08 pm, observation revealed on the lower level floor in the material management system, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included pipes and ductwork for the 2 sprinklers at the South West corner of the room. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

5. On 11/12/2012 at 2:22 pm, observation revealed on the lower level floor in the clean linen room 90.1, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

6. On 11/12/2012 at 2:50 pm, observation revealed on the lower level floor in the Housekeeping room near the garage area, that the space was equipped with both quick response and standard response sprinklers. There were 2 sprinklers of the standard response and 2 sprinklers of the quick response. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-3.1.5.2.

7. On 11/12/2012 at 3:00 pm, observation revealed on the lower level floor in the Laundry room, that the sprinkler installation was not compliant. The sprinkler was covered with lint which would increase the response time of the sprinkler. This observed situation was not compliant with NFPA 101 (2000 ed.).

8. On 11/13/2012 at 7:30 am, observation revealed on the lower level floor in the restroom of PT area, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included a shower curtain that obstructs sprinkler water from reaching the tub. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

9. On 11/13/2012 at 10:00 am, observation revealed on the upper level floor in the patient toilet room 112, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included shower curtains that blocks sprinkler water to the tub. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

10. On 11/14/2012 at 8:00 am, observation revealed on the upper level floor in the room 215.5, ISD room, that there was no sprinkler or approved alternative suppression measures. The building was required to be fully sprinkled because corridor walls are not 1 hour rated. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.1 (exception).

11. On 11/12/2012 at 10:00 am surveyor observed on the lower level in rooms 23 and 24, that the shower curtain was 12 inches from the ceiling creating an obstruction, such that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included no holes in the draw curtain. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5.

12. On 11/12/2012 at 10:15 am surveyor observed on the lower level in room 35, that the ceiling light was 8.5 inches from and 3 inches below the sprinkler head creating an obstruction, such that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5.

13. On 11/12/2012 at 10:20 am surveyor observed on the lower level in stairway containing exit door 16, that the ceiling light was 6 inches from and 2-3/4 inches below the sprinkler head creating an obstruction, such that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5.


These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with neutral airflow between the corridor and rooms, and ventilation systems that comply with NFPA 90A. This deficiency occurred in 3 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/12/2012 at 11:05 am, observation revealed on the lower level floor in Room 53, that airflow between the corridor and this room was not neutral. There was supply air, but no return air. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1 9.2 and NFPA 90A, 2-3.11.1.

2. On 11/12/2012 at 11:10 am, observation revealed on the lower level floor in the Room 57, tissue room, that airflow between the corridor and this room was not neutral. There was exhaust air, yet no supply air was present. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1 9.2 and NFPA 90A, 2-3.11.1.

3. On 11/12/2012 at 2:20 pm, observation revealed on the lower level floor in the hallway near Room 90.1, that the space was not provides with compliant ventilation. It was observed that the fire damper did not have flanges for the duct between lower and the upper level of the building. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.).

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes regarding proper size of storage containers for soiled/trash. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/12/2012 at 11:00 am, observation revealed on the lower level floor in housekeeping Room 32, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. The wheel cart container was 2' X 3' X 2' or 12 cubic feet. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff ID-1 (Director of Facilities).
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Based on observation and record review, the facility did not provide medical gas piping as required by NFPA 99. This deficiency occurred in 4 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/14/2012 at 11:00 am, observation revealed on the lower level floor in the PT area, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included the zone shut off valve was located in the same room as the medical gas outlets. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), Chap 4.

2. On 11/14/2012 at 11:15 am, record review revealed that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included that the items needing repair as identified in the Annual medical gas inspection report of Jan 19, 2012 could not be verified as corrected. This situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), Chap 4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide a code compliant environment with miscellaneous deficiencies, including proper smoke removal system from an anesthetizing location. This deficiency could affect 1 of the 9 smoke compartments and had the potential to affect all of the patients within these smoke compartments that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 11/12/2012 at 10:40 AM, surveyor on the lower floor procedure room of the speciality clinic, observed that there was nitrous oxide (NO2) bottle on a cart and a waste anesthesia gas system in the room. There was not a smoke removal system for this anesthetizing location. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.3 and NFPA 99 (1999 edition) 5.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff I (director of facilities).

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with derangement signals at a continuously monitored location and did not provide a remote stop switch. This deficiency could affect all of the 9 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/12/2012 at 2:58 PM surveyors observed on the lower level floor in the maintenance shop, that audible and visual derangement signals were not located in a continuously monitored location of the maintenance personal. A generator anunciator panel was located in the main entrance (ER area). The observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.2(d) & NFPA 99 (1999 edition), 3-4.1.1.15(b).

2. On 11/13/2012 at 11:10 am, observation revealed on the outside floor in the generator enclosure area, that the emergency generator was not provided with a remote stop switch. The stop shall be outside of the generator enclosure. This observed situation was not compliant with NFPA 110 (1999 ed.), 3-5.5.6.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/12/2012 at 1:05 pm, observation revealed on the lower level floor in the dialysis room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to the refrigerator, fan and copy machine. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide corridor separation doors with doors with positive-latching hardware, self-latching inactive doors, positive-latching hardware, smoke-tight seals at meeting edges, and doors that would close when pushed or pulled. This deficiency occurred in 3 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/12/2012 at 10:50 am, observation revealed on the lower level floor in the health information services Room 37, that the corridor door would not positively self-latch when pushed to a closed position. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.2.

2. On 11/12/2012 at 3:26 pm, observation revealed on the lower level floor in the dinning room, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it had manual latching hardware. The active leaf latched into the inactive leaf. If the inactive leaf would not positively latch, the entire door assembly would not remain closed when a force of 5 pounds is applied. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

3. On 11/13/2012 at 3:00 pm, observation revealed on the upper level floor in the room 150D decontamination (Surgery soiled Utility), that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

4. On 11/14/2012 at 11:30 am, observation revealed on the upper level floor in surgery, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.1.

5. On 11/14/2012 at 1:45 pm, observation revealed on the upper level floor in the laboratory, that the door to the corridor was held open with an electric hold open door operator. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.3.

6. On 11/12/2012 at 10:30 am surveyor observed on the lower level, that the corridor door to the procedure suite of the Speciality Clinic would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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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 2 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/12/2012 at 1:00 pm, observation revealed on the lower level floor in the dialysis equipment room, that penetration(s) were not sealed according to an approved method. The deficiency included 4 conduits above the ceiling, and 1 conduit at the ceiling line. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not enclose hazardous rooms with a closer on all doors, rated wall construction, sealed wall penetrations, sealed wall penetrations, and rated doors. This deficiency occurred in 4 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/12/2012 at 10:45 am, observation revealed on the lower level floor in the soiled utility room of the procedure room of the speciality clinic, that the door would not self-close because there was no closer on the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 and 18.3.6.3.4.

2. On 11/12/2012 at 10:45 am, observation revealed on the lower level floor in the soiled utility room of the procedure room of the speciality clinic, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had an electrical panel, (42" X 26") that exceeded the 100 square inches of electrical outlets in a 100 square feet of rated wall. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

3. On 11/12/2012 at 10:45 am, observation revealed on the lower level floor in the soiled utility room of the procedure room of the speciality clinic, that penetration(s) were not sealed according to an approved method. The deficiency included holes in the rated wall above the ceiling tile. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

4. On 11/12/2012 at 1:20 pm, observation revealed on the lower level floor in the file room (medical records), that penetration(s) were not sealed according to according to an approved method. The deficiency included sewer or drain piping in the SW corner of the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

5. On 11/12/2012 at 2:15 pm, observation revealed on the lower level floor in the garage, that penetration(s) were not sealed according to according to an approved method. The deficiency included the wall not being sealed at the top of the wall to floor interface. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

6. On 11/12/2012 at 2:31 pm, observation revealed on the lower level floor in the Maintenance shop, that penetration(s) were not sealed according to according to an approved method. The deficiency included a polyvinyl chloride PVC pipe that did not have a fire rated collar on it at the south wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

7. On 11/12/2012 at 2:55 pm, observation revealed on the lower level floor in the Housekeeping room near the garage area, that penetration(s) were not sealed according to according to an approved method. The deficiency included a four inch diameter pipe that was not properly sealed to the floor above. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

8. On 11/13/2012 at 3:10 pm, observation revealed on the upper level floor in the room 150D decontamination (Surgery soiled Utility), that the fire barrier door could not be verified to have the required rating. The door was missing to the 'dirty processing area'. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide egress paths at all times with the required signage, and no obstructions in the path of egress. This deficiency occurred in 2 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/13/2012 at 8:20 am, observation revealed on the upper level floor in the storage room 235, that the exit path was not readily accessible because boxes and equipment blocked the door from opening to a fully open position. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

2. On 11/13/2012 at 9:00 am, observation revealed on the upper level floor the OBGYN cross corridor doors has a delayed egress lock (DEL) that did not have the required signage on the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.6.1.

3. On 11/13/2012 at 9:30 am, observation revealed on the upper level floor in the storage room 102, that the exit path was not readily accessible because boxes and equipment blocked the door from opening to a fully open position. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide and maintain emergency illumination of the emergency generator. This deficiency occurred in all of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/13/2012 at 11:00 am, observation revealed at the exterior of the building in the generator enclosure area, that a battery-operated emergency light was not installed in the interior emergency generator location. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.9.2.3, and NFPA 110 (1999 ed.), 5-3.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The facility did not provide a fire alarm system with compliant fire alarm. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/12/2012 at 11:15 am, observation revealed on the lower level floor in meeting Room 92, that the fire alarm installation was not compliant. A strobe for notification of the fire alarm system was missing in the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 1-5.2.5.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with all rooms sprinkled when the code required full sprinkling, sprinklers located the appropriate distance from the ceiling, unobstructed water distribution, matching response sensitivity, all rooms sprinkled when the code required full sprinkling, sprinklers free of obstructions near the ceiling, and all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 5 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/12/2012 at 1:40 pm, observation revealed on the lower level floor in the server room, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The room has a Novec 1230 fire suppression system that does not shut off the return/supply air from the air handler system. This observed situation was not compliant with NFPA 101 (2000 ed.).

2. On 11/12/2012 at 2:00 pm, observation revealed on the lower level floor in the material management system, that 4 sprinklers were located 27" below the obstructed ceiling. Sprinklers can be a maximum of 22" below an obstructed ceiling. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.4.1.1.

3. On 11/12/2012 at 2:03 pm, observation revealed on the lower level floor in the material management system, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included storage above the sprinkler level at the perimeter of the room. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

4. On 11/12/2012 at 2:08 pm, observation revealed on the lower level floor in the material management system, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included pipes and ductwork for the 2 sprinklers at the South West corner of the room. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

5. On 11/12/2012 at 2:22 pm, observation revealed on the lower level floor in the clean linen room 90.1, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

6. On 11/12/2012 at 2:50 pm, observation revealed on the lower level floor in the Housekeeping room near the garage area, that the space was equipped with both quick response and standard response sprinklers. There were 2 sprinklers of the standard response and 2 sprinklers of the quick response. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-3.1.5.2.

7. On 11/12/2012 at 3:00 pm, observation revealed on the lower level floor in the Laundry room, that the sprinkler installation was not compliant. The sprinkler was covered with lint which would increase the response time of the sprinkler. This observed situation was not compliant with NFPA 101 (2000 ed.).

8. On 11/13/2012 at 7:30 am, observation revealed on the lower level floor in the restroom of PT area, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included a shower curtain that obstructs sprinkler water from reaching the tub. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

9. On 11/13/2012 at 10:00 am, observation revealed on the upper level floor in the patient toilet room 112, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included shower curtains that blocks sprinkler water to the tub. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

10. On 11/14/2012 at 8:00 am, observation revealed on the upper level floor in the room 215.5, ISD room, that there was no sprinkler or approved alternative suppression measures. The building was required to be fully sprinkled because corridor walls are not 1 hour rated. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.1 (exception).

11. On 11/12/2012 at 10:00 am surveyor observed on the lower level in rooms 23 and 24, that the shower curtain was 12 inches from the ceiling creating an obstruction, such that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included no holes in the draw curtain. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5.

12. On 11/12/2012 at 10:15 am surveyor observed on the lower level in room 35, that the ceiling light was 8.5 inches from and 3 inches below the sprinkler head creating an obstruction, such that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5.

13. On 11/12/2012 at 10:20 am surveyor observed on the lower level in stairway containing exit door 16, that the ceiling light was 6 inches from and 2-3/4 inches below the sprinkler head creating an obstruction, such that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5.


These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with neutral airflow between the corridor and rooms, and ventilation systems that comply with NFPA 90A. This deficiency occurred in 3 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/12/2012 at 11:05 am, observation revealed on the lower level floor in Room 53, that airflow between the corridor and this room was not neutral. There was supply air, but no return air. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1 9.2 and NFPA 90A, 2-3.11.1.

2. On 11/12/2012 at 11:10 am, observation revealed on the lower level floor in the Room 57, tissue room, that airflow between the corridor and this room was not neutral. There was exhaust air, yet no supply air was present. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1 9.2 and NFPA 90A, 2-3.11.1.

3. On 11/12/2012 at 2:20 pm, observation revealed on the lower level floor in the hallway near Room 90.1, that the space was not provides with compliant ventilation. It was observed that the fire damper did not have flanges for the duct between lower and the upper level of the building. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.).

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes regarding proper size of storage containers for soiled/trash. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/12/2012 at 11:00 am, observation revealed on the lower level floor in housekeeping Room 32, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. The wheel cart container was 2' X 3' X 2' or 12 cubic feet. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff ID-1 (Director of Facilities).
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Based on observation and record review, the facility did not provide medical gas piping as required by NFPA 99. This deficiency occurred in 4 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 11/14/2012 at 11:00 am, observation revealed on the lower level floor in the PT area, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included the zone shut off valve was located in the same room as the medical gas outlets. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), Chap 4.

2. On 11/14/2012 at 11:15 am, record review revealed that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included that the items needing repair as identified in the Annual medical gas inspection report of Jan 19, 2012 could not be verified as corrected. This situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), Chap 4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on observation and interview, the facility did not provide a code compliant environment with miscellaneous deficiencies, including proper smoke removal system from an anesthetizing location. This deficiency could affect 1 of the 9 smoke compartments and had the potential to affect all of the patients within these smoke compartments that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 11/12/2012 at 10:40 AM, surveyor on the lower floor procedure room of the speciality clinic, observed that there was nitrous oxide (NO2) bottle on a cart and a waste anesthesia gas system in the room. There was not a smoke removal system for this anesthetizing location. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.3 and NFPA 99 (1999 edition) 5.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff I (director of facilities).

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with derangement signals at a continuously monitored location and did not provide a remote stop switch. This deficiency could affect all of the 9 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/12/2012 at 2:58 PM surveyors observed on the lower level floor in the maintenance shop, that audible and visual derangement signals were not located in a continuously monitored location of the maintenance personal. A generator anunciator panel was located in the main entrance (ER area). The observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.2(d) & NFPA 99 (1999 edition), 3-4.1.1.15(b).

2. On 11/13/2012 at 11:10 am, observation revealed on the outside floor in the generator enclosure area, that the emergency generator was not provided with a remote stop switch. The stop shall be outside of the generator enclosure. This observed situation was not compliant with NFPA 110 (1999 ed.), 3-5.5.6.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords. This deficiency occurred in 1 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/12/2012 at 1:05 pm, observation revealed on the lower level floor in the dialysis room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to the refrigerator, fan and copy machine. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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