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Based on observation and staff verification the facility failed to ensure the steel was protected throughout the facility. This has the potential to affect all patients receiving services at the facility. The facility census was 118.

Findings include:

1. Observation in the Electrical room located near the Emergency department completed on 06/21/16 revealed two 2 foot sections of unprotected steel noted penetrating the South wall of the Electrical room. These findings were verified by Staff S at the time of the observation.

2. Observation above the drop ceiling in Bay 7 of the cardiac cath area completed on 06/22/16 revealed a section of unprotected steel. This finding was verified by Staff CC at the time of the observation.

3. Observation above the drop ceiling in the corridor between the elevator equipment room and an office space located outside the west wall of the Laboratory area completed on 06/22/16 revealed a 6 foot section of exposed steel close the laboratory west wall. This finding was verified by Staff CC at the time of the observation.

4. Observation in the elevator equipment room completed on 06/22/16 revealed a 8 foot section of exposed steel close to the laboratory west wall. This finding was verified by Staff CC at the time of the observation.


5. Observation of the second floor mechanical rooms was conducted on 06/22/16 between 2:25 PM and 3:30 PM with Staff V. Observation of the open ceiling of the boiler room revealed protected steel support beams. Observation of one beam which penetrated an adjoining wall of another building revealed a section of the support beam that was not protected. Staff V confirmed the finding.

6. On 06/21/16 between 2:55 P.M. and 3:25 P.M. observation of a large electrical room was conducted with Staff CC. Staff CC revealed the room was the electrical room for the service elevators. Penetrations were noted in the ceiling (floor decking) with wire grid over the penetrations. Pieces of cardboard were visible behind the grid. Staff CC indicated the cardboard held "putty' in place. At least two penetrations, approximately three inches in diameter were open in the floor decking


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Based on facility observations and staff interview, the facility failed to ensure corridors were separated from use areas by walls constructed with at least 1/2 hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinkler . This could potentially affect all patients, staff, and visitors in the facility. The facility census was 118 patients.

Findings include:
1. On 06/21/16 from 9:17 AM and 11:48 AM a tour was conducted with Staff V. During this tour, observation revealed an open use lounge area located between 4 North and 4 South units. This area was observed approximately 12 feet by 18 feet in diameter and was equipped with seating. Although the area was observed with an approved automatic sprinkler system, there was no smoke detector or direct supervision of the area. The only smoke detector observed was at the smoke barrier in a nearby vicinity, and in the elevator alcove, but not inside the lounge area.

2. Review of the facility schematic revealed the OR corridors had 30 minute fire rated barrier walls. The operating rooms and corridors surrounding the operating rooms were not provided automatic sprinkler protection. The facility had 10 operating rooms. On 06/22/16 between 8:45 A.M. and 11:30 A.M., observation above the corridor ceiling tiles, utilizing environmental containment units, with Staff U and V was conducted The following observations were confirmed:
a. Located outside OR 2 and OR 3, observation above the ceiling tiles from the corridor side of the operating rooms revealed multiple penetrations in the wall.

b. Observation above the ceiling tiles in the main corridor of the surgical area revealed multiple penetrations of various sizes in the 30 minutes fire rated barrier. A penetration approximately 8 " by 6 " was observed above the main OR (operating room) doors.

c. Observation above the ceiling tiles in the corridor near OR 5 revealed unsealed space at the floor decking. A white tape was noted to seal the seams of the gypsum board for the 30 minute fire rated wall. There was no know fire resistance rating for the white tape.

d. Observation above the ceiling tiles in the corridor outside OR 8 revealed multiple penetrations of varying sizes and shapes.

e. Observation above the ceiling tiles in the corridor between OR's 8 and 9 revealed multiple penetrations of varying sizes and shapes in the walls.

f. Observation of the second floor was conducted on 06/21/16 between 3:30 PM and 4:28 PM with Staff CC. Observation of a corridor near room 271, revealed the area was provided with automatic sprinkler protection. Observation of the ceiling tiles utilized as a partition to resist the passage of smoke revealed at least 15 damaged ceiling tiles that would not resist the passage of smoke.






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3. Tour of the 1st floor was completed on 06/22/16 with Staff DD between the hours of 8:30 AM and 5:30 PM. The following findings were noted in an area that was not protected with an automatic sprinkler system:

a. Observation of the corridor walls of the South corridor beside the Women's health radiology area revealed a 10 inch hole and white pipe with open space around them penetrating the Film room wall.

b. Observation of the corridor wall above the electrical closet by asset doors 3191 revealed multiple large openings varying in size and shape.

c. Observation of the corridor wall above the dressing room next to CT Scan 2 revealed a 24 inch by 14 inch hole and opening around 4 inch conduits.

d. Observation of the corridor wall above CT Scan 1 room revealed multiple penetrations varying in size and shape.

All findings were verified by Staff DD at the time of the observations.

Based on facility observations and staff interview and confirmation, the facility failed to ensure that corridor room doors resisted the passage of smoke as required by the code at 19.3.6.3.1 and NFPA 80, 2.3.1.7. There is no impediment to the closing of the doors This involved corridor doors on all floors of the facility. The facility census was 118 patients.
Findings include:
1. A tour was conducted on the fourth floor on 06/21/16 between 9:17 AM and 11:48 AM, and on the third floor on 06/21/16 between 2:30 PM and 4:30 PM with Staff V.
During this tour the following patient room doors failed to resist the passage of smoke due to gaps between door leafs or failure to latch into the frame:
a. On the fourth floor, the patient rooms with greater than 1/8 inch openings between door leaf meeting edges were rooms 4030 (1/4 inch gap) and 4018 (3/8 inch gap). Each wooden door was observed with two leafs, one wider active leaf and one smaller inactive leaf. The smaller leaf was equipped with a latching mechanism near the top inside of the door which was used to latch the door into the frame. The wider door leaf contained a latching mechanism which latched into the strike plate of the smaller door leaf. Staff V measured the gaps and confirmed the measurements exceeded 1/8 inch.
b. On the third floor the following patient corridor doors failed to latch into the frame when tested: Rooms 3110, 3011, and 3023. The following patient room doors did latch into the frame with difficulty due to rubbing the door frames: Rooms 3018, 3031, and 3133.
Staff V confirmed these doors on tour.

2. On 06/21/16 between 9:35 A.M. and 11:50 A.M. observation of the intensive care area was conducted with Staff U and X. Review of the facility schematic revealed the area was not considered a suite. Patient rooms, 2133, 2131, 2129, 2127 and 2123 were occupied. Room 2123 was identified as a room used when a patient required isolation protocols due to infection control. Observation of the doorway to the room revealed a red biohazard container container placed directly in front the door.

Each patient room in the ICU had two leaf doors, which, when opened, allowed the bed to be moved easily in or out of the room. Observation of the patient's rooms revealed electronic portable work stations sitting at the doorways At least one room was noted with the small leaf of the door folded back and the portable work station directly in front of the door. Small chairs were also placed at some work stations in the doorways to the rooms. Placement of the work stations, chairs and biohazard containers in front of the patient room doors required staff to first move the items in order to close the patient room doors in the event of a fire emergency. Staff present on tour confirmed the observations.




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3. On 06/22/16, observation of the first floor emergency department was conducted with Staff DD. Observation the room doors located in the emergency department revealed the latching hardware failed to function in rooms 7, 18, and 22.

These findings were verified by Staff DD at the time of the observation.

Based on observations, review of architectural drawings, and staff interviews, the facility failed to ensure stairways, elevator shafts, and ventilation shafts maintained the identified fire resistance rating as required in the code at 8.2.5. This involved an elevator shaft, ventilation shafts and stairways of the facility. This could potentially affect all patients in the facility. The facility census was 118 patients.
Findings include:
1. A tour with Staff V was conducted on 06/21/16 between 9:17 AM and 11:48 AM. The elevator shaft across from the open lounge area between 4 North and 4 South units was observed with a curved conduit measuring ¾ inch in diameter which was open inside the conduit. A review of architectural drawings revealed a two hour fire resistance rated wall around the elevator shafts.
2. On 3 South, a tour with Staff V on 06/21/16 between 2:30 PM and 4:30 PM revealed two heating and ventilation shafts (HVAC). The HVAC shaft located inside the nurses ' station closest to room 3125 was observed with a metal stud immediately above the drop down ceiling. This top portion of this metal stud was measured at 36 inches wide and 3 and 3/8 in height. The metal was inserted into the outer layer of the 5/8 drywall which was cut out to accommodate the metal piece. This was confirmed with Staff V at the time of observation.
On 3 South, an HVAC ventilation shaft inside the nurses ' station near room 3110 was observed with approximately a 4 wide by 2 inch high cut-out in two layers of 5/8 inch drywall (each layer). This opening was observed with blue data wires and was located over the drop down ceiling. This same ventilation shaft drywall was observed with an electrical box which contained a penetration in the two layers of drywall. The electrical box was located on the same ventilator shaft wall approximately 4 feet above the floor inside the nurses ' station. This was confirmed with Staff V at the time of observation.
A review of architectural drawings revealed a two hour fire resistance rated wall around the ventilation shafts.
3. Observation of the second floor intensive care area was conducted on 06/21/16 between 9:35 A.M. and 11:50 A.M. with Staff U and X. Review of facility schematic indicated a large chase with one hour fire rated separation which extended though the upper floors Observation from an access panel, located in the critical care internist office, revealed a significant portion of the construction was incomplete. Staff U and Staff T confirmed the chase was not separated by one hour fire rated construction.

4. Observation of Stairway D, at the first floor, revealed a penetration in the two hour fire rated wall of the stairwell at the discharge to the first floor. The penetration allowed an ink pen to be inserted at least six inches. Staff U and X confirmed the observation. Review of the facility schematics confirmed the stairway was to be separated by two hour fire rated construction.

5. Observation on 06/21/16 between 2:55 P.M. and 3:25 P.M. with Staff CC of a chase located near the operating room storage area. Review of the facility schematic revealed the chase was to be separated by two hour fire rated construction. Observation above the ceiling tiles of the two hour fire rated barrier wall revealed three open ended conduit and flex that was not sealed and penetrated the barrier wall. Observation of the same barrier wall from the corridor side of the chase, revealed a large duct in the chase. Portions of the interior barrier wall looked to be missing. A chipped, broken piece of gypsum was visible at the corner, floor level, just inside the door to the shaft.

Based on review of facility evacuation plans, facility observations, and staff interview, the facility failed to ensure fire doors located in the egress stairwells latched into the frame when tested in accordance with the code at 8.2.5., and failed to provide evidence of the fire resistance rating on a stairwell doors. This could potentially affect all patients and visitors in the facility. The facility census was 118 patients.

Findings include:

1) A tour was conducted on 06/21/16 between 9:17 AM and 11:48 AM with Staff V. The A stairway door on the fourth floor failed to latch into the frame when tested on the first two attempts. The facility evacuation plan identified this stairway as an egress stairway. This was confirmed with Staff V during tour.

2) During tour of the third floor on 06/21/16 between 2:30 PM and 4:30 PM with Staff V, the A stairway door was observed with a fire protection rating label on the side of the door. However, this label was observed with scratch marks, making the label illegible. This was confirmed with Staff V at the time of the observation.

3) Observation of Stairway D, at the first floor revealed the door on first floor had a metal tag that was to indicate the fire protection of the door. The label was scratched over, making the fire rating of the door unidentifiable. The observation was confirmed by Staff U.

4) On 06/21/16 at 4:30 P.M. observation of Stairway B door, located on the second floor with Staff CC and X, revealed the door had a 30 minute fire resistance rating. The stairway door was part of the two hour fire rated enclosure of the stairwell. Staff present confirmed the observation.

Based on review of facility schematics, observation of the facility and staff interview and confirmation, the facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers on three of four floors of the facility were affected. Potentially all patients and visitors could be affected. The facility had a census of 118 patients.

Findings include:

FOURTH FLOOR;

Tour was conducted on the fourth floor on 06/21/16 between 9:17 AM and 11:48 AM, and on the third floor on 06/21/16 between 2:30 PM and 4:30 PM with Staff V.
On the fourth floor by room 4029, the smoke barrier was observed with one 3/4 inch diameter conduit which contained wires. The inside of the conduit was observed open around the wires. Another conduit measuring approximately four inches in diameter was observed open inside around blue, yellow, and white wires on one side the barrier.

SECOND FLOOR

1. On 06/21/16 at 11:50 A.M., observation above the ceiling tiles in the men's locker room located near the critical care unit, revealed penetrations where four conduit passes through the one hour fire rated barrier.

2. On 06/21/16 at 2:40 P.M., observation above the ceiling tiles in the surgeons's locker room located near the critical care unit, revealed a penetration three to four inches in diameter with conduit passed through the one hour fire rated barrier.

The following observations were noted in a one hour fire rated smoke barrier wall between 2:55 P.M. and 4:30 P.M. with Staff CC and Staff X.

3. Observation above the ceiling tiles at a door leading to the operating rooms and the anesthesia on call room of a one hour fire rated smoke barrier wall with Staff CC revealed five penetrations. The penetrations included unsealed space surrounding flex, conduits and penetrations for wire.

4. Observed in the same corridor, above the ceiling tiles, across from room 252, at least two penetrations approximately three inches in diameter in the one hour fire rated smoke barrier.

5. Observation of a large electrical room was conducted with Staff CC. Review of facility schematic revealed that two walls of the room were part of a one hour fire rated smoke barrier wall. Staff CC revealed the room was the electrical room for the service elevators. Penetrations noted in the designated one hour fire rated smoke barrier wall were approximately two inches long and six inches in width. An additional penetration was noted to be approximately two inches in diameter.

6. Observation above the ceiling tiles at the main operating room doors, revealed a penetration approximately eight inches wide and six inches in length. Signage on the other side of the smoke barrier wall, located in the operating room corridor, was visible.

7. Observation above the ceiling tiles in the pharmacy corridor, near the obstetrical surgery door, a penetration approximately two inches square was noted.

8. Observed in the same pharmacy corridor, a 10 inch square gray box with no cover was secured to the one hour fire rated wall. There was no identifiable fire rating for the steel box. Additionally a pipe sleeve with phone and data wires, inserted through the wall was not sealed at the end.

9. Observed above the PT/OT office door, a pipe sleeve, approximately two inches in diameter with wire running through the pipe, was not sealed at the open ends. A white garden hose was noted to penetrate the fire rated wall. The ends of the garden hose were open.

Staff present on tour confirmed the observations.

Tour of a portion of the second floor was conducted on 06/22/16 between 9:00 AM and 11:45 AM with Staff V.

10. Observation of the one hour fire rated barrier located outside the OR storage room revealed multiple penetrations of varying sizes and shapes.

11. Observation above the ceiling tiles of the one hour fire rated smoke barrier wall located above the corridor doors leading from OR hallway to Same Day Surgery revealed multiple penetrations of varying sizes and shapes. The one hour fire rated barrier was without a continuous wall extending to floor slab above. The Same Day Surgery pre-operative and post operative care is located in a newly renovated space.

12. Observations above the ceiling tiles revealed multiple penetrations of varying sizes and shapes in the one hour fire rated wall located across from the clean utility room in the post anesthesia care unit(PACU) of the endoscopy. The PACU is located in a newly renovated space of the second floor.

Staff V confirmed the findings.



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FIRST FLOOR

Tour of the 1st floor was conducted on 06/21/16 between the hours of 1:30 PM and 5:00 PM and the following observations were made.

1. Observation of the East wall above the North double doors to the Emergency Department (ED) as seen from the corridor outside the ED revealed 4 X 4 inch hole with 1 red data cable passing through.

2. Observation of the East wall above the central single door (Asset 3240) to the ED as seen from the corridor outside the ED revealed a 3/4 inch flex conduit with blue ring open on end and open annular space.

3. Observation of the East wall of Employee health as seen from the corridor side revealed multiple penetration varying in size and shape.

4. Observation above the double doors to the corridor running along side the ED as seen from the corridor running East and West North of the Cath lab revealed multiple penetrations varying in size and shape. The fire doors also failed to close to latching position when tested.

5. Observation of the fire rated wall above the door leading to ED running from the East corridor beside the Electrical room as seen from this corridor revealed 3 inch conduit with open annular space.

6. Observation above the double doors from the West hospital entrance to the waiting room for the ED as seen from the ED waiting room revealed a large opening with pink insulation behind steel column and 2 small rectangular openings just above the drop ceiling.

7. Observation above the double doors from the West hospital entrance to the waiting room for the ED as seen from the West hospital entrance revealed multiple penetrations varying in size and shape.

8. Observation of the East wall of Pre-admission testing as seen from the West hospital entrance side offices, revealed no fire rated material and not sealed a deck above.

9. Observation of the East fire rated smoke wall of the ED as seen from the family waiting room revealed a large HVAC and a 6 inch water pipe with open annular space, and the wall not sealed at deck above.

10. Observation of the East fire rated smoke wall of the ED as seen from the shell space behind the trauma room revealed multiple penetrations varying in size and shape and open ended conduits.

11. Observation above the double doors from the West hospital entrance to the South most corridor as seen from the entrance side revealed a 3/4 inch conduit open on the end with 2 red data cable passing through and open annular space.

All findings were verified by Staff S at the time of the observations.

Tour of the 1st floor was completed on 06/22/16 between the hours of 8:30 AM and 5:30 PM and the following observations were made.

1. Observation of the West wall of the pre-admission testing nurses station revealed no fire rated material was used to seal penetration in the wall.

2. Observation of the West and South walls of bay 6 in the Cath Lab area revealed no fire rated material was used to seal penetrations in the walls.

3. Observation above the door between the Cath Lab and Respiratory area as seen from the Cath Lab side revealed no wall present for about 13 foot span. Testing of the door revealed the door did not close to latching position.

4. Observation of the East wall in the Women's locker room, as seen from within the locker room, of the Cath Lab revealed two 12 inch by 5 inch holes.

5. Observation above the double doors in the South most corridor beside the elevator equipment room as seen from the West side of the doors revealed three 1 1/2 inch holes with flex conduits passing through.

6. Observation above the double doors in the South most corridor beside the elevator equipment room as seen from the East side of the doors revealed multiple penetrations varying in size and shape.

7. Observation of the West wall of the kitchen area double doors located just outside the business occupancy separation as seen from inside the kitchen area revealed a large area of block busted out with a conduit passing through.

8. Observation of the West wall of the kitchen storage area revealed a 2 foot by 1 foot hole with sprinkler lines passing through.

9. Observation above the double doors located in the South most corridor that runs East and West just outside the kitchen area revealed multiple penetrations varying in size and shape on both sides of the double doors.

10. Observation above the double doors located beside the Southeast elevators revealed multiple penetrations varying in size and shape on both sides of the double doors.

11. Observation of the West wall of medical records as seen from within medical records revealed multiple penetrations varying in size and shape.

12. Observation of the West wall of the office beside medical records as seen from within the office revealed multiple penetrations varying in size and shape.

13. Observation of the South wall in the Physician lounge/dining room revealed multiple penetrations varying in size and shape.

14. Observation of the East wall of the Coder office revealed multiple penetrations varying in size and shape and paper tape used to seal the deck above.

15. Observation of the West Clinical Storage room as seen from the corridor side revealed an HVAC duct with a 1 inch gap above and 1/4 inch flex with open annular space was noted above the door to the Hurt team leader office.

16. Observation of the fire rated smoke wall at the corner of corridor outside the "old cashier office" revealed steel support at deck with open space where it penetrated the wall.

17. Observation above the East side of the double doors with Asset number 3157 revealed multiple penetrations varying in size and shape and a gray material used to seal one of the openings. A request was made for the rating of the gray material to Staff CC at the time of the observation, non was received.

18. Observation of the North and West walls, as seen from the corner of the wall in women's health waiting room, revealed a 1 inch penetration with a gray data cable passing through.

19. Observation of the West fire rated smoke wall of women's health as seen from the corridor revealed the wall not sealed at deck above across from the radiology dressing room.

20. Observation above the East and west sides of the double doors outside the laboratory area with asset number 3225 revealed multiple penetrations varying in size and shape.

21. Observation above the East side of the double doors the the North of Central Sterilization with asset number 4623 revealed multiple penetrations varying in size and shape.

22. Observation of the East wall of DaVita Dialysis area revealed a 3/4 inch copper pipe with open annular space.

All findings were verified by Staff DD at the time of the observations.

Based on facility observation and staff interview and confirmation the facility failed to ensure that door openings in smoke barriers had at least a 20-minute fire protection rating. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Doors are self-closing or automatic closing in accordance with 19.2.2.2.6. Potentially all patients and visitors in the areas could be affected. The facility had a census of 118 patients.

Findings include:

1. A tour was conducted on the fourth floor on 06/21/16 between 9:17 AM and 11:48 AM with Staff V. The latching fire doors located on 4 North by room 4016 failed to latch into the frame when tested.

An additional pair of fire rated doors located at the entrance to 4 South was observed with a 90 minute fire resistance rated label. These doors were tested by releasing them from the magnetic hold open device. One of the two doors failed to latch into the frame during the test.

Staff V confirmed the observation.

2. On 06/22/16 between 8:45 A.M. and 11:30 A.M., observation of the operating room main corridor was conducted with Staff U. Observation of the second floor operating room main corridor, revealed doors identified as fire doors with a 20 minute fire resistance rating. These fire doors were on hold-open devices which released upon activation of the fire alarm. The doors were manually released to allow closure with no positive latching of the doors observed.
Staff present on tour confirmed the observations.

Based on review of facility schematic, facility observation and staff interview and confirmation, the facility failed to ensure that one hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. Potentially all patients and visitors could be affected. The facility had a census of 118 patients.

Findings include:

SECOND FLOOR

1. On 06/22/16 between 8:35 A.M. and 12:00 P.M., tour of the facility was conducted with Staff U and X of the storage area for surgical supplies. Observation of the facility schematic indicated the storage area was separated by one hour fire rated walls. Observation above the ceiling tiles revealed the following penetrations in the fire rated wall:

a. Located in the metro room, a penetration approximately one inch in diameter with red wire through the opening.

b. Located in the operating room storage area, other side of the metro room, a penetration approximately one inch in diameter with red wire . Additional penetrations in the fire rated wall included another opening approximately one inch in diameter with gray cable and a square cut for an electrical box approximately three inches in diameter.

Observations were confirmed by Staff U.

2. On 06/22/16 between 9:00 AM and 11:45 AM observation of the second floor soiled utility room for the surgical area was conducted with Staff V. Review of the facility schematic indicated the soiled utility room was separated by one hour fire rated construction. Observation above the ceiling tiles from the corridor side ( near OR 8) of the fire rated wall revealed multiple penetrations of varying sizes and shapes . Staff V confirmed the observation.

3. Review of the facility schematics for the second floor revealed mechanical rooms separated by two hour fire rated construction. On 06/22/16 between 2:25 P.M. and 3:30 P.M. tour of the mechanical rooms was conducted with Staff V. The following observations were noted in the mechanical rooms of the second floor;
a. Double doors located within the two hour fire rated barrier which connected from a common corridor to the boiler room had a fire resistance rating of 20 minutes.
b. A single door located in the two hour fire rated barrier leading from the mechanical room to the maintenance shop had a 20 minute fire resistance rating.
c. Double doors in a two hour fire rated barrier wall joining the boiler room and the mechanical room had a 20 minute fire resistance rating.
d. A door located in the two hour fire rated barrier wall which opened from the mechanical room to a waiting area had no identifiable fire resistance rating.
e. Double doors, located in the two hour fire rated wall, outside the mechanical area opened to a lobby area had to identifiable fire resistance rating.
f. Multiple penetrations, various sizes , were observed in the two hour fire rated wall which separated the boiler room and the mechanical rooms One penetration involved a protected steel beam that connected to an unprotected steel beam through a common wall.
Staff V, present on tour, confirmed the observations.

4. On 06/22/16 between 9:00 A.M. and 11:45 A.M. tour of the newly renovated space for the Same Day Surgery and the Endoscopy pre-operative and post operative care units was conducted with Staff V. Review of the facility schematic revealed a one hour fire rated barrier wall which separated the soiled utility rooms and the medical supply rooms.

Observations of the one hour fire rated walls, above the ceiling tiles, revealed multiple penetrations of varying sizes and shapes in the fire rated wall of the medication/supply room located in Endoscopy/PACU (post anesthesia care unit).

Observation of the soiled utility room located in the Same Day Surgery center revealed one penetration approximately 16 inches by 20 inches and two additional penetrations approximately 12 inches by 10 inches each. Staff V present on tour confirmed the observations.

Staff V, present on tour, confirmed the observations.


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FIRST FLOOR;

5. Tour of the first floor was conducted on 06/21/16 between the hours of 1:30 PM and 5:00 PM and the following observations were made.

A. Observation of the walls of the Electrical room beside the Emergency Department revealed three 3 foot by 2 1/2 foot openings around unprotected steel in the South wall of the room, and the North, West, and South walls not sealed at deck above.

B. Observation of the East wall of the Electrical room as seen from the corridor revealed multiple penetrations varying in size and shape.

C. Observation of the North wall of the Electrical room as seen from the corridor revealed the wall not sealed at deck with a fire rated material.

All findings were verified by Staff S at the time of the observations.

Tour of the first floor was completed on 06/22/16 between the hours of 8:30 AM and 5:30 PM and the following observations were made.

D. Observation of a general storage area located across from the soiled utility room in the Emergency department revealed no fire rated wall at the corridor, just a curtain between the space and the corridor.

E. Observation of the door for the clean utility room located in the Cath Lab revealed no fire rating on the door.

F. Observation of the West wall of the storage area between the West hospital entrance and the Cath Lab as seen from in the Cath Lab revealed 6 open ended conduits with blue data cables passing through.

G. Observation of the West Mechanical Space wall as seen from the Echo lab revealed white line insulation with open center and no water line passing through, a a water line with open annular space.

H. Observation of the South wall of the elevator equipment room for the elevators by the main lobby as seen from the data closet revealed 14 inch by 18 inch hole with a drain pipe penetrating it.

I. Observation of the South wall of the elevator equipment room for the elevators by the main lobby as seen from inside the room revealed a 3 inch hole toward the back of the room.

J. Observation of the North wall of the elevator equipment room for the elevators by the main lobby as seen from inside the Clinical Storage room revealed multiple penetrations and large open areas varying in size and shape.

K. Observation above the drop ceiling in the pediatric area med room revealed open ended conduits in the North, South, and East walls.

L. Observation of the wall across from the cooler located in the Laboratory area as seen from within the Laboratory space revealed multiple penetrations varying in size and shape and not sealed at deck above.

M. Observation of the North and East walls of the Histology Room revealed no fire rated material around the penetrations and seams of the room, the walls were not sealed at deck above with a fire rated material.

N. Observation of the South wall above the West most door to the corridor located in the Laboratory area revealed large openings with yellow insulation, requested information on the fire rating on the yellow insulation from Staff DD at the time of the observation and none was provided before exiting the facility on 06/23/16.

O. Observation of the South Laboratory wall as seen from the corridor revealed multiple penetrations varying in size and shape.

P. Observation of the West wall of the physician sleeping area revealed one layer of drywall between the space and the Laboratory area.

All findings were verified by Staff DD at the time of the observations.

Based on facility observations and staff interviews, the facility failed to ensure smoke detectors were located at least 36 inches from air movement devices in accordance with the code at 9.6.1.4 and NFPA 72, 2-3.5.1. This involved patient care areas throughout the facility. This could potentially affect all patients and visitors. The facility census was 118 patients.

Findings include:

FOURTH FLOOR

A tour was conducted on 06/21/16 between 9:17 AM and 11:48 AM with Staff V on the fourth floor and on the third floor between 2:30 PM and 4:30 PM with Staff V.
Staff V confirmed the following observations of smoke detectors less than 36 inches from air diffusers, stating they need to be relocated:
On the fourth floor:
At 4 North, in the service area across from patient room 4029 the smoke detector in the clean utility room, in the soiled utility room, and in the staff break room.
At 4 South, in the break room by the elevator and in the southeast storage room by the HVAC ventilation vertical opening.

THIRD FLOOR

On 3 North in the staff break room in the service hall, the soiled utility room in the service hall, the clean utility room in the service hall, immediately outside the clean utility room in the service hall, in the ante room outside patient room 3009 and in the nurses station across from room 3009.

On 3 South, at the smoke barrier door entrance into 3 South by room 3138, in the corridor outside room 3103, in the corridor outside room 3109 and in the corridor outside room 3125.

SECOND FLOOR

On 06/21/16 between 9:17 AM and 11:48 AM., tour was conducted with Staff U. Observation of the second floor critical care internist office revealed a smoke detector placed within 18 inches of an air flow device.

Observation of the second floor equipment storage area in the critical acre area revealed a smoke detector placed within 18 inches of an air flow device.

Observation of the second floor men's and women's bathrooms located in the respective locker rooms area revealed a smoke detector placed within 10 to 12 inches of an air flow device.

On 06/22/16 between 8:35 A.M. and 12:00 P.M. tour of the facility was conducted with Staff U of the operating room area. Observation of the following smoke detectors revealed they were located significantly closer than 36 inches from air movement devices;

a. Located near the nursing station, a smoke detector approximately 18 inches from an air vent.

b. Located outside the biohazard room, a smoke detector approximately 18 inches from an air flow device.

c. Located in the corridor near the main doors, a smoke detector approximately 12 inches from an air flow device.

d. Located in the perfusion storage area for the open heart surgery room, a smoke detector approximately 12 inches from an air flow device.

e. Located in the center core corridor, a smoke detector approximately 12 inches from an air flow device.

f. Multiple PSD (photoelectric smoke detectors) located less than 36 inches from an air register including in room 252, in the corridor outside the surgical storage room, the main pharmacy corridor, the corridor leading the maternity unit and outside the door leading to peri-operative services.



FIRST FLOOR

On 06/22/16 between 8:35 A.M. and 12:00 P.M. tour of the facility was conducted with Staff U of the central processing area on the first floor. Smoke detectors observed in the staff break room and near the dumbwaiter were approximately 18 inches from air flow devices.

Staff present on tour confirmed the observations.

Based on observation and staff interview the facility failed to ensure sprinkler heads were of the same response type in a smoke compartment. This has the potential to affect all patients receiving services from the facility. The facility's inpatient census was 118.

Findings include:

Observation of the sprinkler heads located at the entrances of the Laboratory space and in the Histology room completed on 06/22/16 revealed quick response sprinkler heads, throughout the rest of the Laboratory space smoke compartment standard response sprinkler heads were noted.

Interview with Staff DD at the time of the observation on 06/22/16 revealed the quick response sprinkler heads were installed when the areas were remodeled and the new cooler was installed.

Based on observation, documentation review, and staff verification the facility failed to ensure quarterly testing of the sprinkler system was completed, sprinkler heads were free of debris, and a sprinkler box with spare heads and wrench were located at the sprinkler riser. This has the potential to affect all patients receiving services at the facility.


Findings include:


1. During tour of the facility completed on 06/23/16 revealed sprinkler heads located in treatment rooms 1, 2, 3, and 4, and two sprinkler heads located in the corridor by the treatment rooms were covered with debris. These findings were verified by Staff DD at the time of the observations.

2. Observation of the sprinkler riser for the 3rd floor located on the 3rd floor completed on 06/23/16 revealed no sprinkler box with spare heads and a sprinkler head wrench. These findings were verified by Staff DD at the time of the observation.

3. During documentation review completed on 06/23/16 revealed no documentation of quarterly sprinkler testing. Request was made for all the testing completed at the offsite locations on 06/20/16, 06/21/16, and 06/23/16.

4. Interview with Staff S completed on 06/23/16 revealed the facility did not have documentation of the quarterly sprinkler testing to provide.

Based on facility observation, review of preventative maintenance documentation and staff interview and confirmation, the facilty failed to ensure that heating, ventilating, and air conditioning complied with the provisions of section 9.2 and were installed in accordance with the manufacturer's specifications. The facilty had a census of 118 patients at the time of survey. Potentially all patients and visitors could be adversely affected.


Findings included:


On 06/21/16 through 06/22/16 tour of the facilty was conducted with Staff U, CC, V and X. Observations included areas above ceiling tiles and each floor of the facilty. Observation above the ceiling tiles on each floor revealed duct work with dampers labeled as smoke dampers or fire dampers.

On 06/23/16 between 9:30 A.M. and 12:30 P.M. review of facility preventative maintenance and fire safety documentation was conducted with Staff S and T. Review of fire and smoke damper testing documentation completed by a contracted company revealed the facilty dampers were inspected between July 2014 and December 2014.

A detailed report of the fire and smoke damper inspection revealed the following;

1. The first floor had 29 smoke dampers, 41 fire dampers and 45 combination dampers which were inspected between 10/07/14 and 10/29/14. Combination dampers were motorized smoke dampers and fusible link fire dampers in the same duct. The report revealed that 45 of 115 total dampers failed.

2. Second floor had 43 smoke dampers, 32 fire dampers and 58 combination dampers which were inspected between 10/29/14 and 12/05/14. The report revealed that 58 of 133 total dampers failed on the second floor.

3. The third floor had 14 smoke dampers, 4 fire dampers and 6 combination dampers which were inspected between 07/25/14 and 08/07/4. The report revealed that 18 of 24 total dampers failed.

4. The fourth floor had 8 smoke dampers, 5 fire dampers and 21 combination dampers which were inspected 07/08/14 through 07/25/14. The report revealed that 14 of 34 total dampers failed.

A deficiency report summarized the damper inspection for each floor. The majority of damper failures were related to inaccessibility of the damper to be inspected and/or mechanical failure of the devices. Staff S and T, present at the document review, were interviewed regarding repairs or placement of access panels for the dampers identified on the 2014 report. Staff confirmed the damper work was on a plan for future work and was not completed.

Based on facility observation, review of preventative maintenance documentation and staff interview and confirmation, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standard for Health Care Facilities. That oxygen storage locations of greater than 3,000 cu.ft. were enclosed by a one-hour separation and that locations for supply systems of greater than 3,000 cu.ft. were vented to the outside. The facility had a census of 118 patients at the time of survey. Potentially all patients, staff and visitors could be adversely affected.

Findings included:


1. On 06/21/16 between 10:05 A.M. and 11:50 A.M. tour of the facility was conducted with Staff U and X. Observation of the first floor medical as storage area (tank room) revealed significant storage, greater than 3,000 cu.ft., of oxygen, nitrous oxide and other medical gases. Observation of the room revealed there was no vent located one foot from the floor of the room which vented to the outside.

A copper pipe, with open space surrounding the pipe was observed to penetrated the two hour fire rated wall of the medical gas storage room.

2. Observation of the second floor obstetrical unit (OB) on 06/22/16 with Staff U and X revealed patient rooms for labor, delivery and recovery (LDR) of mothers and infants. Each room was provided with a headwall where piped in oxygen and medical air was available for mothers and infants. Observation outside the rooms revealed there as no area alarm panel for the oxygen system.

3. Observation of the second floor room 273, identified as the respiratory therapy storage room revealed 11, E-sized oxygen tanks, 7 carbon dioxide tanks and at least 2, C-size medical air tanks. The room had no fire rated separation and a door with a 20 minute fire rating. Signage outside the room noted there was medical gases stored within the room.

Observations were confirmed by staff present on the tour.

4. On 06/23/16 between 9:30 A.M. and 12:30 P.M. review of facility preventative maintenance and fire safety documentation was conducted with Staff S and T. Review of an inspection report for the medical gas system, conducted in March 2016 by a contracted company, revealed the medical gas tank room where the manifold system was located, needed ventilation (a vent) one foot off the floor. Additionally, the report noted the LDR area required an alarm and there was none. The comprehensive report also noted various leaking valves and changes that needed to be completed on the oxygen/ nitrous oxide delivery system.

Interview of Staff S and T revealed the repair work needed was placed on a plan for future improvement (PFI) and was recently converted to work orders. Staff confirmed the work was not completed.

38.7.1 Drills.
In any business occupancy building occupied by more than 500 persons or more than 100 persons above or below the street level, employees and supervisory personnel shall be periodically instructed in accordance with Section 4.7 and shall hold drills periodically where practicable.


Based on documentation review and staff interview the facility failed to ensure fire drills were held periodically at unexpected days and times. This has the potential to affect all patients receiving services at the facility.

Findings include:

1. Review of the occupancy permit for the 3rd floor completed on 06/23/16 revealed an occupant load of 153.

2. During documentation review completed on 06/23/16 revealed no documentation of fire drills being completed at the facility. This finding was confirmed by Staff S on 06/23/16.


38.3.1.1
Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

Based on observation and staff verification the facility failed to ensure doors in the vertical stairwell closed to latching position. This has the potential to affect all patients receiving services at the facility.

Findings include:

During tour of the facility completed on 06/23/16 revealed first floor door in the East Stairwell failed to close to latching position. The tour also revealed the second and first floor doors in the West Stairwell failed to close to latching position. These findings were verified by Staff DD at the time of the observation.


38.2.9.1
Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 50 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 300 or more total occupants.

Based on observation, documentation review, and staff interview the facility failed to ensure battery operated lighting in the exit egress functioned appropriately and were tested monthly and annually as per NFPA 101. This has the potential to affect all patients receiving services at the facility.

Findings include:

1. During tour of the facility completed on 06/23/16 revealed the emergency lighting located in the East and West stairwells between the 1st and 2nd floors failed to operate when the test buttons were pushed.

This finding was verified by Staff DD at the time of the observation.

2. Interview with Staff DD at the time of the tour completed on 06/23/16 revealed the lights in the path of egress from the lights between the 1st and 2nd floors in the stairwells to exit discharge are not tested by the facility.

3. Review of the emergency light testing completed on 06/23/16 revealed the battery operated emergency lights in the exit egress are not listed as being tested. This finding was verified by Staff S at the time of the documentation review.

38.2.10 Marking of Means of Egress.
Means of egress shall have signs in accordance with Section 7.10.

Based on observation and staff verification the facility failed to ensure lighted exit signage functioned appropriately in the exit egress path.

This has the potential to affect all patients receiving services at the facility.

Findings include:

During tour of the facility completed on 06/23/16 revealed the exit light above the East exit door on the first floor was not lit and failed to function when the test button was pushed. This finding was verified by Staff DD at the time of the observation.


Based on observation the facility failed to provide safe access to public way, as per NFPA 101 section 38.2.7 in accordance with section 7.7.1. This has the potential to affect all patients that receive services from the facility.


Findings include:

Tour of the facility conducted on 06/23/16 revealed an exit discharge at the east exit, exited to a 4 feet by 3 feet concrete pad then to a grass covered area with 12 inch stepping pavers encompassing a 40 foot distance to the parking area. This finding was verified by Staff DD at the time of the observation.

7-3.2* Testing.
Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

Based on observation, documentation review, and staff interview the facility failed to ensure Single Station Smoke Detectors were tested in accordance with NFPA 72. This has the potential to affect all patients receiving services from the facility.

Findings include:

1. During tour of the facility completed on 06/21/16 revealed single station smoke detectors throughout the facility.

2. During documentation review completed on 06/23/16 revealed no documentation of testing for the smoke detectors in the facility.

3. Interview with Staff S completed on 06/23/16 at 1:30 PM revealed the facility does not have documentation of the smoke detector testing for the facility.

Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 50 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 300 or more total occupants.


Based on observation, documentation review, and staff interview the facility failed to ensure battery operated lighting in the exit egress functioned appropriately and were tested monthly and annually as per NFPA 101. This has the potential to affect all patients receiving services at the facility.

Findings include:

1. During tour of the facility completed on 06/23/16 revealed the emergency lighting located in the two exit egress paths. This finding was verified by Staff DD at the time of the observation.

2. Interview with Staff DD at the time of the tour completed on 06/23/16 revealed the lights in the path of egress after leaving the entrance to the facility's entrance was not tested.

3. Review of the emergency light testing completed on 06/23/16 revealed the battery operated emergency lights in the exit egress are not listed as being tested. This finding was verified by Staff S at the time of the documentation review.

Based on observation and staff verification the facility failed to ensure the steel was protected throughout the facility. This has the potential to affect all patients receiving services at the facility. The facility census was 118.

Findings include:

1. Observation in the Electrical room located near the Emergency department completed on 06/21/16 revealed two 2 foot sections of unprotected steel noted penetrating the South wall of the Electrical room. These findings were verified by Staff S at the time of the observation.

2. Observation above the drop ceiling in Bay 7 of the cardiac cath area completed on 06/22/16 revealed a section of unprotected steel. This finding was verified by Staff CC at the time of the observation.

3. Observation above the drop ceiling in the corridor between the elevator equipment room and an office space located outside the west wall of the Laboratory area completed on 06/22/16 revealed a 6 foot section of exposed steel close the laboratory west wall. This finding was verified by Staff CC at the time of the observation.

4. Observation in the elevator equipment room completed on 06/22/16 revealed a 8 foot section of exposed steel close to the laboratory west wall. This finding was verified by Staff CC at the time of the observation.


5. Observation of the second floor mechanical rooms was conducted on 06/22/16 between 2:25 PM and 3:30 PM with Staff V. Observation of the open ceiling of the boiler room revealed protected steel support beams. Observation of one beam which penetrated an adjoining wall of another building revealed a section of the support beam that was not protected. Staff V confirmed the finding.

6. On 06/21/16 between 2:55 P.M. and 3:25 P.M. observation of a large electrical room was conducted with Staff CC. Staff CC revealed the room was the electrical room for the service elevators. Penetrations were noted in the ceiling (floor decking) with wire grid over the penetrations. Pieces of cardboard were visible behind the grid. Staff CC indicated the cardboard held "putty' in place. At least two penetrations, approximately three inches in diameter were open in the floor decking


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Based on facility observations and staff interview, the facility failed to ensure corridors were separated from use areas by walls constructed with at least 1/2 hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinkler . This could potentially affect all patients, staff, and visitors in the facility. The facility census was 118 patients.

Findings include:
1. On 06/21/16 from 9:17 AM and 11:48 AM a tour was conducted with Staff V. During this tour, observation revealed an open use lounge area located between 4 North and 4 South units. This area was observed approximately 12 feet by 18 feet in diameter and was equipped with seating. Although the area was observed with an approved automatic sprinkler system, there was no smoke detector or direct supervision of the area. The only smoke detector observed was at the smoke barrier in a nearby vicinity, and in the elevator alcove, but not inside the lounge area.

2. Review of the facility schematic revealed the OR corridors had 30 minute fire rated barrier walls. The operating rooms and corridors surrounding the operating rooms were not provided automatic sprinkler protection. The facility had 10 operating rooms. On 06/22/16 between 8:45 A.M. and 11:30 A.M., observation above the corridor ceiling tiles, utilizing environmental containment units, with Staff U and V was conducted The following observations were confirmed:
a. Located outside OR 2 and OR 3, observation above the ceiling tiles from the corridor side of the operating rooms revealed multiple penetrations in the wall.

b. Observation above the ceiling tiles in the main corridor of the surgical area revealed multiple penetrations of various sizes in the 30 minutes fire rated barrier. A penetration approximately 8 " by 6 " was observed above the main OR (operating room) doors.

c. Observation above the ceiling tiles in the corridor near OR 5 revealed unsealed space at the floor decking. A white tape was noted to seal the seams of the gypsum board for the 30 minute fire rated wall. There was no know fire resistance rating for the white tape.

d. Observation above the ceiling tiles in the corridor outside OR 8 revealed multiple penetrations of varying sizes and shapes.

e. Observation above the ceiling tiles in the corridor between OR's 8 and 9 revealed multiple penetrations of varying sizes and shapes in the walls.

f. Observation of the second floor was conducted on 06/21/16 between 3:30 PM and 4:28 PM with Staff CC. Observation of a corridor near room 271, revealed the area was provided with automatic sprinkler protection. Observation of the ceiling tiles utilized as a partition to resist the passage of smoke revealed at least 15 damaged ceiling tiles that would not resist the passage of smoke.






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3. Tour of the 1st floor was completed on 06/22/16 with Staff DD between the hours of 8:30 AM and 5:30 PM. The following findings were noted in an area that was not protected with an automatic sprinkler system:

a. Observation of the corridor walls of the South corridor beside the Women's health radiology area revealed a 10 inch hole and white pipe with open space around them penetrating the Film room wall.

b. Observation of the corridor wall above the electrical closet by asset doors 3191 revealed multiple large openings varying in size and shape.

c. Observation of the corridor wall above the dressing room next to CT Scan 2 revealed a 24 inch by 14 inch hole and opening around 4 inch conduits.

d. Observation of the corridor wall above CT Scan 1 room revealed multiple penetrations varying in size and shape.

All findings were verified by Staff DD at the time of the observations.

Based on facility observations and staff interview and confirmation, the facility failed to ensure that corridor room doors resisted the passage of smoke as required by the code at 19.3.6.3.1 and NFPA 80, 2.3.1.7. There is no impediment to the closing of the doors This involved corridor doors on all floors of the facility. The facility census was 118 patients.
Findings include:
1. A tour was conducted on the fourth floor on 06/21/16 between 9:17 AM and 11:48 AM, and on the third floor on 06/21/16 between 2:30 PM and 4:30 PM with Staff V.
During this tour the following patient room doors failed to resist the passage of smoke due to gaps between door leafs or failure to latch into the frame:
a. On the fourth floor, the patient rooms with greater than 1/8 inch openings between door leaf meeting edges were rooms 4030 (1/4 inch gap) and 4018 (3/8 inch gap). Each wooden door was observed with two leafs, one wider active leaf and one smaller inactive leaf. The smaller leaf was equipped with a latching mechanism near the top inside of the door which was used to latch the door into the frame. The wider door leaf contained a latching mechanism which latched into the strike plate of the smaller door leaf. Staff V measured the gaps and confirmed the measurements exceeded 1/8 inch.
b. On the third floor the following patient corridor doors failed to latch into the frame when tested: Rooms 3110, 3011, and 3023. The following patient room doors did latch into the frame with difficulty due to rubbing the door frames: Rooms 3018, 3031, and 3133.
Staff V confirmed these doors on tour.

2. On 06/21/16 between 9:35 A.M. and 11:50 A.M. observation of the intensive care area was conducted with Staff U and X. Review of the facility schematic revealed the area was not considered a suite. Patient rooms, 2133, 2131, 2129, 2127 and 2123 were occupied. Room 2123 was identified as a room used when a patient required isolation protocols due to infection control. Observation of the doorway to the room revealed a red biohazard container container placed directly in front the door.

Each patient room in the ICU had two leaf doors, which, when opened, allowed the bed to be moved easily in or out of the room. Observation of the patient's rooms revealed electronic portable work stations sitting at the doorways At least one room was noted with the small leaf of the door folded back and the portable work station directly in front of the door. Small chairs were also placed at some work stations in the doorways to the rooms. Placement of the work stations, chairs and biohazard containers in front of the patient room doors required staff to first move the items in order to close the patient room doors in the event of a fire emergency. Staff present on tour confirmed the observations.




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3. On 06/22/16, observation of the first floor emergency department was conducted with Staff DD. Observation the room doors located in the emergency department revealed the latching hardware failed to function in rooms 7, 18, and 22.

These findings were verified by Staff DD at the time of the observation.

Based on observations, review of architectural drawings, and staff interviews, the facility failed to ensure stairways, elevator shafts, and ventilation shafts maintained the identified fire resistance rating as required in the code at 8.2.5. This involved an elevator shaft, ventilation shafts and stairways of the facility. This could potentially affect all patients in the facility. The facility census was 118 patients.
Findings include:
1. A tour with Staff V was conducted on 06/21/16 between 9:17 AM and 11:48 AM. The elevator shaft across from the open lounge area between 4 North and 4 South units was observed with a curved conduit measuring ¾ inch in diameter which was open inside the conduit. A review of architectural drawings revealed a two hour fire resistance rated wall around the elevator shafts.
2. On 3 South, a tour with Staff V on 06/21/16 between 2:30 PM and 4:30 PM revealed two heating and ventilation shafts (HVAC). The HVAC shaft located inside the nurses ' station closest to room 3125 was observed with a metal stud immediately above the drop down ceiling. This top portion of this metal stud was measured at 36 inches wide and 3 and 3/8 in height. The metal was inserted into the outer layer of the 5/8 drywall which was cut out to accommodate the metal piece. This was confirmed with Staff V at the time of observation.
On 3 South, an HVAC ventilation shaft inside the nurses ' station near room 3110 was observed with approximately a 4 wide by 2 inch high cut-out in two layers of 5/8 inch drywall (each layer). This opening was observed with blue data wires and was located over the drop down ceiling. This same ventilation shaft drywall was observed with an electrical box which contained a penetration in the two layers of drywall. The electrical box was located on the same ventilator shaft wall approximately 4 feet above the floor inside the nurses ' station. This was confirmed with Staff V at the time of observation.
A review of architectural drawings revealed a two hour fire resistance rated wall around the ventilation shafts.
3. Observation of the second floor intensive care area was conducted on 06/21/16 between 9:35 A.M. and 11:50 A.M. with Staff U and X. Review of facility schematic indicated a large chase with one hour fire rated separation which extended though the upper floors Observation from an access panel, located in the critical care internist office, revealed a significant portion of the construction was incomplete. Staff U and Staff T confirmed the chase was not separated by one hour fire rated construction.

4. Observation of Stairway D, at the first floor, revealed a penetration in the two hour fire rated wall of the stairwell at the discharge to the first floor. The penetration allowed an ink pen to be inserted at least six inches. Staff U and X confirmed the observation. Review of the facility schematics confirmed the stairway was to be separated by two hour fire rated construction.

5. Observation on 06/21/16 between 2:55 P.M. and 3:25 P.M. with Staff CC of a chase located near the operating room storage area. Review of the facility schematic revealed the chase was to be separated by two hour fire rated construction. Observation above the ceiling tiles of the two hour fire rated barrier wall revealed three open ended conduit and flex that was not sealed and penetrated the barrier wall. Observation of the same barrier wall from the corridor side of the chase, revealed a large duct in the chase. Portions of the interior barrier wall looked to be missing. A chipped, broken piece of gypsum was visible at the corner, floor level, just inside the door to the shaft.

Based on review of facility evacuation plans, facility observations, and staff interview, the facility failed to ensure fire doors located in the egress stairwells latched into the frame when tested in accordance with the code at 8.2.5., and failed to provide evidence of the fire resistance rating on a stairwell doors. This could potentially affect all patients and visitors in the facility. The facility census was 118 patients.

Findings include:

1) A tour was conducted on 06/21/16 between 9:17 AM and 11:48 AM with Staff V. The A stairway door on the fourth floor failed to latch into the frame when tested on the first two attempts. The facility evacuation plan identified this stairway as an egress stairway. This was confirmed with Staff V during tour.

2) During tour of the third floor on 06/21/16 between 2:30 PM and 4:30 PM with Staff V, the A stairway door was observed with a fire protection rating label on the side of the door. However, this label was observed with scratch marks, making the label illegible. This was confirmed with Staff V at the time of the observation.

3) Observation of Stairway D, at the first floor revealed the door on first floor had a metal tag that was to indicate the fire protection of the door. The label was scratched over, making the fire rating of the door unidentifiable. The observation was confirmed by Staff U.

4) On 06/21/16 at 4:30 P.M. observation of Stairway B door, located on the second floor with Staff CC and X, revealed the door had a 30 minute fire resistance rating. The stairway door was part of the two hour fire rated enclosure of the stairwell. Staff present confirmed the observation.

Based on review of facility schematics, observation of the facility and staff interview and confirmation, the facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers on three of four floors of the facility were affected. Potentially all patients and visitors could be affected. The facility had a census of 118 patients.

Findings include:

FOURTH FLOOR;

Tour was conducted on the fourth floor on 06/21/16 between 9:17 AM and 11:48 AM, and on the third floor on 06/21/16 between 2:30 PM and 4:30 PM with Staff V.
On the fourth floor by room 4029, the smoke barrier was observed with one 3/4 inch diameter conduit which contained wires. The inside of the conduit was observed open around the wires. Another conduit measuring approximately four inches in diameter was observed open inside around blue, yellow, and white wires on one side the barrier.

SECOND FLOOR

1. On 06/21/16 at 11:50 A.M., observation above the ceiling tiles in the men's locker room located near the critical care unit, revealed penetrations where four conduit passes through the one hour fire rated barrier.

2. On 06/21/16 at 2:40 P.M., observation above the ceiling tiles in the surgeons's locker room located near the critical care unit, revealed a penetration three to four inches in diameter with conduit passed through the one hour fire rated barrier.

The following observations were noted in a one hour fire rated smoke barrier wall between 2:55 P.M. and 4:30 P.M. with Staff CC and Staff X.

3. Observation above the ceiling tiles at a door leading to the operating rooms and the anesthesia on call room of a one hour fire rated smoke barrier wall with Staff CC revealed five penetrations. The penetrations included unsealed space surrounding flex, conduits and penetrations for wire.

4. Observed in the same corridor, above the ceiling tiles, across from room 252, at least two penetrations approximately three inches in diameter in the one hour fire rated smoke barrier.

5. Observation of a large electrical room was conducted with Staff CC. Review of facility schematic revealed that two walls of the room were part of a one hour fire rated smoke barrier wall. Staff CC revealed the room was the electrical room for the service elevators. Penetrations noted in the designated one hour fire rated smoke barrier wall were approximately two inches long and six inches in width. An additional penetration was noted to be approximately two inches in diameter.

6. Observation above the ceiling tiles at the main operating room doors, revealed a penetration approximately eight inches wide and six inches in length. Signage on the other side of the smoke barrier wall, located in the operating room corridor, was visible.

7. Observation above the ceiling tiles in the pharmacy corridor, near the obstetrical surgery door, a penetration approximately two inches square was noted.

8. Observed in the same pharmacy corridor, a 10 inch square gray box with no cover was secured to the one hour fire rated wall. There was no identifiable fire rating for the steel box. Additionally a pipe sleeve with phone and data wires, inserted through the wall was not sealed at the end.

9. Observed above the PT/OT office door, a pipe sleeve, approximately two inches in diameter with wire running through the pipe, was not sealed at the open ends. A white garden hose was noted to penetrate the fire rated wall. The ends of the garden hose were open.

Staff present on tour confirmed the observations.

Tour of a portion of the second floor was conducted on 06/22/16 between 9:00 AM and 11:45 AM with Staff V.

10. Observation of the one hour fire rated barrier located outside the OR storage room revealed multiple penetrations of varying sizes and shapes.

11. Observation above the ceiling tiles of the one hour fire rated smoke barrier wall located above the corridor doors leading from OR hallway to Same Day Surgery revealed multiple penetrations of varying sizes and shapes. The one hour fire rated barrier was without a continuous wall extending to floor slab above. The Same Day Surgery pre-operative and post operative care is located in a newly renovated space.

12. Observations above the ceiling tiles revealed multiple penetrations of varying sizes and shapes in the one hour fire rated wall located across from the clean utility room in the post anesthesia care unit(PACU) of the endoscopy. The PACU is located in a newly renovated space of the second floor.

Staff V confirmed the findings.



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FIRST FLOOR

Tour of the 1st floor was conducted on 06/21/16 between the hours of 1:30 PM and 5:00 PM and the following observations were made.

1. Observation of the East wall above the North double doors to the Emergency Department (ED) as seen from the corridor outside the ED revealed 4 X 4 inch hole with 1 red data cable passing through.

2. Observation of the East wall above the central single door (Asset 3240) to the ED as seen from the corridor outside the ED revealed a 3/4 inch flex conduit with blue ring open on end and open annular space.

3. Observation of the East wall of Employee health as seen from the corridor side revealed multiple penetration varying in size and shape.

4. Observation above the double doors to the corridor running along side the ED as seen from the corridor running East and West North of the Cath lab revealed multiple penetrations varying in size and shape. The fire doors also failed to close to latching position when tested.

5. Observation of the fire rated wall above the door leading to ED running from the East corridor beside the Electrical room as seen from this corridor revealed 3 inch conduit with open annular space.

6. Observation above the double doors from the West hospital entrance to the waiting room for the ED as seen from the ED waiting room revealed a large opening with pink insulation behind steel column and 2 small rectangular openings just above the drop ceiling.

7. Observation above the double doors from the West hospital entrance to the waiting room for the ED as seen from the West hospital entrance revealed multiple penetrations varying in size and shape.

8. Observation of the East wall of Pre-admission testing as seen from the West hospital entrance side offices, revealed no fire rated material and not sealed a deck above.

9. Observation of the East fire rated smoke wall of the ED as seen from the family waiting room revealed a large HVAC and a 6 inch water pipe with open annular space, and the wall not sealed at deck above.

10. Observation of the East fire rated smoke wall of the ED as seen from the shell space behind the trauma room revealed multiple penetrations varying in size and shape and open ended conduits.

11. Observation above the double doors from the West hospital entrance to the South most corridor as seen from the entrance side revealed a 3/4 inch conduit open on the end with 2 red data cable passing through and open annular space.

All findings were verified by Staff S at the time of the observations.

Tour of the 1st floor was completed on 06/22/16 between the hours of 8:30 AM and 5:30 PM and the following observations were made.

1. Observation of the West wall of the pre-admission testing nurses station revealed no fire rated material was used to seal penetration in the wall.

2. Observation of the West and South walls of bay 6 in the Cath Lab area revealed no fire rated material was used to seal penetrations in the walls.

3. Observation above the door between the Cath Lab and Respiratory area as seen from the Cath Lab side revealed no wall present for about 13 foot span. Testing of the door revealed the door did not close to latching position.

4. Observation of the East wall in the Women's locker room, as seen from within the locker room, of the Cath Lab revealed two 12 inch by 5 inch holes.

5. Observation above the double doors in the South most corridor beside the elevator equipment room as seen from the West side of the doors revealed three 1 1/2 inch holes with flex conduits passing through.

6. Observation above the double doors in the South most corridor beside the elevator equipment room as seen from the East side of the doors revealed multiple penetrations varying in size and shape.

7. Observation of the West wall of the kitchen area double doors located just outside the business occupancy separation as seen from inside the kitchen area revealed a large area of block busted out with a conduit passing through.

8. Observation of the West wall of the kitchen storage area revealed a 2 foot by 1 foot hole with sprinkler lines passing through.

9. Observation above the double doors located in the South most corridor that runs East and West just outside the kitchen area revealed multiple penetrations varying in size and shape on both sides of the double doors.

10. Observation above the double doors located beside the Southeast elevators revealed multiple penetrations varying in size and shape on both sides of the double doors.

11. Observation of the West wall of medical records as seen from within medical records revealed multiple penetrations varying in size and shape.

12. Observation of the West wall of the office beside medical records as seen from within the office revealed multiple penetrations varying in size and shape.

13. Observation of the South wall in the Physician lounge/dining room revealed multiple penetrations varying in size and shape.

14. Observation of the East wall of the Coder office revealed multiple penetrations varying in size and shape and paper tape used to seal the deck above.

15. Observation of the West Clinical Storage room as seen from the corridor side revealed an HVAC duct with a 1 inch gap above and 1/4 inch flex with open annular space was noted above the door to the Hurt team leader office.

16. Observation of the fire rated smoke wall at the corner of corridor outside the "old cashier office" revealed steel support at deck with open space where it penetrated the wall.

17. Observation above the East side of the double doors with Asset number 3157 revealed multiple penetrations varying in size and shape and a gray material used to seal one of the openings. A request was made for the rating of the gray material to Staff CC at the time of the observation, non was received.

18. Observation of the North and West walls, as seen from the corner of the wall in women's health waiting room, revealed a 1 inch penetration with a gray data cable passing through.

19. Observation of the West fire rated smoke wall of women's health as seen from the corridor revealed the wall not sealed at deck above across from the radiology dressing room.

20. Observation above the East and west sides of the double doors outside the laboratory area with asset number 3225 revealed multiple penetrations varying in size and shape.

21. Observation above the East side of the double doors the the North of Central Sterilization with asset number 4623 revealed multiple penetrations varying in size and shape.

22. Observation of the East wall of DaVita Dialysis area revealed a 3/4 inch copper pipe with open annular space.

All findings were verified by Staff DD at the time of the observations.

Based on facility observation and staff interview and confirmation the facility failed to ensure that door openings in smoke barriers had at least a 20-minute fire protection rating. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Doors are self-closing or automatic closing in accordance with 19.2.2.2.6. Potentially all patients and visitors in the areas could be affected. The facility had a census of 118 patients.

Findings include:

1. A tour was conducted on the fourth floor on 06/21/16 between 9:17 AM and 11:48 AM with Staff V. The latching fire doors located on 4 North by room 4016 failed to latch into the frame when tested.

An additional pair of fire rated doors located at the entrance to 4 South was observed with a 90 minute fire resistance rated label. These doors were tested by releasing them from the magnetic hold open device. One of the two doors failed to latch into the frame during the test.

Staff V confirmed the observation.

2. On 06/22/16 between 8:45 A.M. and 11:30 A.M., observation of the operating room main corridor was conducted with Staff U. Observation of the second floor operating room main corridor, revealed doors identified as fire doors with a 20 minute fire resistance rating. These fire doors were on hold-open devices which released upon activation of the fire alarm. The doors were manually released to allow closure with no positive latching of the doors observed.
Staff present on tour confirmed the observations.

Based on review of facility schematic, facility observation and staff interview and confirmation, the facility failed to ensure that one hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. Potentially all patients and visitors could be affected. The facility had a census of 118 patients.

Findings include:

SECOND FLOOR

1. On 06/22/16 between 8:35 A.M. and 12:00 P.M., tour of the facility was conducted with Staff U and X of the storage area for surgical supplies. Observation of the facility schematic indicated the storage area was separated by one hour fire rated walls. Observation above the ceiling tiles revealed the following penetrations in the fire rated wall:

a. Located in the metro room, a penetration approximately one inch in diameter with red wire through the opening.

b. Located in the operating room storage area, other side of the metro room, a penetration approximately one inch in diameter with red wire . Additional penetrations in the fire rated wall included another opening approximately one inch in diameter with gray cable and a square cut for an electrical box approximately three inches in diameter.

Observations were confirmed by Staff U.

2. On 06/22/16 between 9:00 AM and 11:45 AM observation of the second floor soiled utility room for the surgical area was conducted with Staff V. Review of the facility schematic indicated the soiled utility room was separated by one hour fire rated construction. Observation above the ceiling tiles from the corridor side ( near OR 8) of the fire rated wall revealed multiple penetrations of varying sizes and shapes . Staff V confirmed the observation.

3. Review of the facility schematics for the second floor revealed mechanical rooms separated by two hour fire rated construction. On 06/22/16 between 2:25 P.M. and 3:30 P.M. tour of the mechanical rooms was conducted with Staff V. The following observations were noted in the mechanical rooms of the second floor;
a. Double doors located within the two hour fire rated barrier which connected from a common corridor to the boiler room had a fire resistance rating of 20 minutes.
b. A single door located in the two hour fire rated barrier leading from the mechanical room to the maintenance shop had a 20 minute fire resistance rating.
c. Double doors in a two hour fire rated barrier wall joining the boiler room and the mechanical room had a 20 minute fire resistance rating.
d. A door located in the two hour fire rated barrier wall which opened from the mechanical room to a waiting area had no identifiable fire resistance rating.
e. Double doors, located in the two hour fire rated wall, outside the mechanical area opened to a lobby area had to identifiable fire resistance rating.
f. Multiple penetrations, various sizes , were observed in the two hour fire rated wall which separated the boiler room and the mechanical rooms One penetration involved a protected steel beam that connected to an unprotected steel beam through a common wall.
Staff V, present on tour, confirmed the observations.

4. On 06/22/16 between 9:00 A.M. and 11:45 A.M. tour of the newly renovated space for the Same Day Surgery and the Endoscopy pre-operative and post operative care units was conducted with Staff V. Review of the facility schematic revealed a one hour fire rated barrier wall which separated the soiled utility rooms and the medical supply rooms.

Observations of the one hour fire rated walls, above the ceiling tiles, revealed multiple penetrations of varying sizes and shapes in the fire rated wall of the medication/supply room located in Endoscopy/PACU (post anesthesia care unit).

Observation of the soiled utility room located in the Same Day Surgery center revealed one penetration approximately 16 inches by 20 inches and two additional penetrations approximately 12 inches by 10 inches each. Staff V present on tour confirmed the observations.

Staff V, present on tour, confirmed the observations.


31007

FIRST FLOOR;

5. Tour of the first floor was conducted on 06/21/16 between the hours of 1:30 PM and 5:00 PM and the following observations were made.

A. Observation of the walls of the Electrical room beside the Emergency Department revealed three 3 foot by 2 1/2 foot openings around unprotected steel in the South wall of the room, and the North, West, and South walls not sealed at deck above.

B. Observation of the East wall of the Electrical room as seen from the corridor revealed multiple penetrations varying in size and shape.

C. Observation of the North wall of the Electrical room as seen from the corridor revealed the wall not sealed at deck with a fire rated material.

All findings were verified by Staff S at the time of the observations.

Tour of the first floor was completed on 06/22/16 between the hours of 8:30 AM and 5:30 PM and the following observations were made.

D. Observation of a general storage area located across from the soiled utility room in the Emergency department revealed no fire rated wall at the corridor, just a curtain between the space and the corridor.

E. Observation of the door for the clean utility room located in the Cath Lab revealed no fire rating on the door.

F. Observation of the West wall of the storage area between the West hospital entrance and the Cath Lab as seen from in the Cath Lab revealed 6 open ended conduits with blue data cables passing through.

G. Observation of the West Mechanical Space wall as seen from the Echo lab revealed white line insulation with open center and no water line passing through, a a water line with open annular space.

H. Observation of the South wall of the elevator equipment room for the elevators by the main lobby as seen from the data closet revealed 14 inch by 18 inch hole with a drain pipe penetrating it.

I. Observation of the South wall of the elevator equipment room for the elevators by the main lobby as seen from inside the room revealed a 3 inch hole toward the back of the room.

J. Observation of the North wall of the elevator equipment room for the elevators by the main lobby as seen from inside the Clinical Storage room revealed multiple penetrations and large open areas varying in size and shape.

K. Observation above the drop ceiling in the pediatric area med room revealed open ended conduits in the North, South, and East walls.

L. Observation of the wall across from the cooler located in the Laboratory area as seen from within the Laboratory space revealed multiple penetrations varying in size and shape and not sealed at deck above.

M. Observation of the North and East walls of the Histology Room revealed no fire rated material around the penetrations and seams of the room, the walls were not sealed at deck above with a fire rated material.

N. Observation of the South wall above the West most door to the corridor located in the Laboratory area revealed large openings with yellow insulation, requested information on the fire rating on the yellow insulation from Staff DD at the time of the observation and none was provided before exiting the facility on 06/23/16.

O. Observation of the South Laboratory wall as seen from the corridor revealed multiple penetrations varying in size and shape.

P. Observation of the West wall of the physician sleeping area revealed one layer of drywall between the space and the Laboratory area.

All findings were verified by Staff DD at the time of the observations.

Based on facility observations and staff interviews, the facility failed to ensure smoke detectors were located at least 36 inches from air movement devices in accordance with the code at 9.6.1.4 and NFPA 72, 2-3.5.1. This involved patient care areas throughout the facility. This could potentially affect all patients and visitors. The facility census was 118 patients.

Findings include:

FOURTH FLOOR

A tour was conducted on 06/21/16 between 9:17 AM and 11:48 AM with Staff V on the fourth floor and on the third floor between 2:30 PM and 4:30 PM with Staff V.
Staff V confirmed the following observations of smoke detectors less than 36 inches from air diffusers, stating they need to be relocated:
On the fourth floor:
At 4 North, in the service area across from patient room 4029 the smoke detector in the clean utility room, in the soiled utility room, and in the staff break room.
At 4 South, in the break room by the elevator and in the southeast storage room by the HVAC ventilation vertical opening.

THIRD FLOOR

On 3 North in the staff break room in the service hall, the soiled utility room in the service hall, the clean utility room in the service hall, immediately outside the clean utility room in the service hall, in the ante room outside patient room 3009 and in the nurses station across from room 3009.

On 3 South, at the smoke barrier door entrance into 3 South by room 3138, in the corridor outside room 3103, in the corridor outside room 3109 and in the corridor outside room 3125.

SECOND FLOOR

On 06/21/16 between 9:17 AM and 11:48 AM., tour was conducted with Staff U. Observation of the second floor critical care internist office revealed a smoke detector placed within 18 inches of an air flow device.

Observation of the second floor equipment storage area in the critical acre area revealed a smoke detector placed within 18 inches of an air flow device.

Observation of the second floor men's and women's bathrooms located in the respective locker rooms area revealed a smoke detector placed within 10 to 12 inches of an air flow device.

On 06/22/16 between 8:35 A.M. and 12:00 P.M. tour of the facility was conducted with Staff U of the operating room area. Observation of the following smoke detectors revealed they were located significantly closer than 36 inches from air movement devices;

a. Located near the nursing station, a smoke detector approximately 18 inches from an air vent.

b. Located outside the biohazard room, a smoke detector approximately 18 inches from an air flow device.

c. Located in the corridor near the main doors, a smoke detector approximately 12 inches from an air flow device.

d. Located in the perfusion storage area for the open heart surgery room, a smoke detector approximately 12 inches from an air flow device.

e. Located in the center core corridor, a smoke detector approximately 12 inches from an air flow device.

f. Multiple PSD (photoelectric smoke detectors) located less than 36 inches from an air register including in room 252, in the corridor outside the surgical storage room, the main pharmacy corridor, the corridor leading the maternity unit and outside the door leading to peri-operative services.



FIRST FLOOR

On 06/22/16 between 8:35 A.M. and 12:00 P.M. tour of the facility was conducted with Staff U of the central processing area on the first floor. Smoke detectors observed in the staff break room and near the dumbwaiter were approximately 18 inches from air flow devices.

Staff present on tour confirmed the observations.

Based on observation and staff interview the facility failed to ensure sprinkler heads were of the same response type in a smoke compartment. This has the potential to affect all patients receiving services from the facility. The facility's inpatient census was 118.

Findings include:

Observation of the sprinkler heads located at the entrances of the Laboratory space and in the Histology room completed on 06/22/16 revealed quick response sprinkler heads, throughout the rest of the Laboratory space smoke compartment standard response sprinkler heads were noted.

Interview with Staff DD at the time of the observation on 06/22/16 revealed the quick response sprinkler heads were installed when the areas were remodeled and the new cooler was installed.

Based on observation, documentation review, and staff verification the facility failed to ensure quarterly testing of the sprinkler system was completed, sprinkler heads were free of debris, and a sprinkler box with spare heads and wrench were located at the sprinkler riser. This has the potential to affect all patients receiving services at the facility.


Findings include:


1. During tour of the facility completed on 06/23/16 revealed sprinkler heads located in treatment rooms 1, 2, 3, and 4, and two sprinkler heads located in the corridor by the treatment rooms were covered with debris. These findings were verified by Staff DD at the time of the observations.

2. Observation of the sprinkler riser for the 3rd floor located on the 3rd floor completed on 06/23/16 revealed no sprinkler box with spare heads and a sprinkler head wrench. These findings were verified by Staff DD at the time of the observation.

3. During documentation review completed on 06/23/16 revealed no documentation of quarterly sprinkler testing. Request was made for all the testing completed at the offsite locations on 06/20/16, 06/21/16, and 06/23/16.

4. Interview with Staff S completed on 06/23/16 revealed the facility did not have documentation of the quarterly sprinkler testing to provide.

Based on facility observation, review of preventative maintenance documentation and staff interview and confirmation, the facilty failed to ensure that heating, ventilating, and air conditioning complied with the provisions of section 9.2 and were installed in accordance with the manufacturer's specifications. The facilty had a census of 118 patients at the time of survey. Potentially all patients and visitors could be adversely affected.


Findings included:


On 06/21/16 through 06/22/16 tour of the facilty was conducted with Staff U, CC, V and X. Observations included areas above ceiling tiles and each floor of the facilty. Observation above the ceiling tiles on each floor revealed duct work with dampers labeled as smoke dampers or fire dampers.

On 06/23/16 between 9:30 A.M. and 12:30 P.M. review of facility preventative maintenance and fire safety documentation was conducted with Staff S and T. Review of fire and smoke damper testing documentation completed by a contracted company revealed the facilty dampers were inspected between July 2014 and December 2014.

A detailed report of the fire and smoke damper inspection revealed the following;

1. The first floor had 29 smoke dampers, 41 fire dampers and 45 combination dampers which were inspected between 10/07/14 and 10/29/14. Combination dampers were motorized smoke dampers and fusible link fire dampers in the same duct. The report revealed that 45 of 115 total dampers failed.

2. Second floor had 43 smoke dampers, 32 fire dampers and 58 combination dampers which were inspected between 10/29/14 and 12/05/14. The report revealed that 58 of 133 total dampers failed on the second floor.

3. The third floor had 14 smoke dampers, 4 fire dampers and 6 combination dampers which were inspected between 07/25/14 and 08/07/4. The report revealed that 18 of 24 total dampers failed.

4. The fourth floor had 8 smoke dampers, 5 fire dampers and 21 combination dampers which were inspected 07/08/14 through 07/25/14. The report revealed that 14 of 34 total dampers failed.

A deficiency report summarized the damper inspection for each floor. The majority of damper failures were related to inaccessibility of the damper to be inspected and/or mechanical failure of the devices. Staff S and T, present at the document review, were interviewed regarding repairs or placement of access panels for the dampers identified on the 2014 report. Staff confirmed the damper work was on a plan for future work and was not completed.

Based on facility observation, review of preventative maintenance documentation and staff interview and confirmation, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standard for Health Care Facilities. That oxygen storage locations of greater than 3,000 cu.ft. were enclosed by a one-hour separation and that locations for supply systems of greater than 3,000 cu.ft. were vented to the outside. The facility had a census of 118 patients at the time of survey. Potentially all patients, staff and visitors could be adversely affected.

Findings included:


1. On 06/21/16 between 10:05 A.M. and 11:50 A.M. tour of the facility was conducted with Staff U and X. Observation of the first floor medical as storage area (tank room) revealed significant storage, greater than 3,000 cu.ft., of oxygen, nitrous oxide and other medical gases. Observation of the room revealed there was no vent located one foot from the floor of the room which vented to the outside.

A copper pipe, with open space surrounding the pipe was observed to penetrated the two hour fire rated wall of the medical gas storage room.

2. Observation of the second floor obstetrical unit (OB) on 06/22/16 with Staff U and X revealed patient rooms for labor, delivery and recovery (LDR) of mothers and infants. Each room was provided with a headwall where piped in oxygen and medical air was available for mothers and infants. Observation outside the rooms revealed there as no area alarm panel for the oxygen system.

3. Observation of the second floor room 273, identified as the respiratory therapy storage room revealed 11, E-sized oxygen tanks, 7 carbon dioxide tanks and at least 2, C-size medical air tanks. The room had no fire rated separation and a door with a 20 minute fire rating. Signage outside the room noted there was medical gases stored within the room.

Observations were confirmed by staff present on the tour.

4. On 06/23/16 between 9:30 A.M. and 12:30 P.M. review of facility preventative maintenance and fire safety documentation was conducted with Staff S and T. Review of an inspection report for the medical gas system, conducted in March 2016 by a contracted company, revealed the medical gas tank room where the manifold system was located, needed ventilation (a vent) one foot off the floor. Additionally, the report noted the LDR area required an alarm and there was none. The comprehensive report also noted various leaking valves and changes that needed to be completed on the oxygen/ nitrous oxide delivery system.

Interview of Staff S and T revealed the repair work needed was placed on a plan for future improvement (PFI) and was recently converted to work orders. Staff confirmed the work was not completed.

38.7.1 Drills.
In any business occupancy building occupied by more than 500 persons or more than 100 persons above or below the street level, employees and supervisory personnel shall be periodically instructed in accordance with Section 4.7 and shall hold drills periodically where practicable.


Based on documentation review and staff interview the facility failed to ensure fire drills were held periodically at unexpected days and times. This has the potential to affect all patients receiving services at the facility.

Findings include:

1. Review of the occupancy permit for the 3rd floor completed on 06/23/16 revealed an occupant load of 153.

2. During documentation review completed on 06/23/16 revealed no documentation of fire drills being completed at the facility. This finding was confirmed by Staff S on 06/23/16.


38.3.1.1
Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

Based on observation and staff verification the facility failed to ensure doors in the vertical stairwell closed to latching position. This has the potential to affect all patients receiving services at the facility.

Findings include:

During tour of the facility completed on 06/23/16 revealed first floor door in the East Stairwell failed to close to latching position. The tour also revealed the second and first floor doors in the West Stairwell failed to close to latching position. These findings were verified by Staff DD at the time of the observation.


38.2.9.1
Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 50 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 300 or more total occupants.

Based on observation, documentation review, and staff interview the facility failed to ensure battery operated lighting in the exit egress functioned appropriately and were tested monthly and annually as per NFPA 101. This has the potential to affect all patients receiving services at the facility.

Findings include:

1. During tour of the facility completed on 06/23/16 revealed the emergency lighting located in the East and West stairwells between the 1st and 2nd floors failed to operate when the test buttons were pushed.

This finding was verified by Staff DD at the time of the observation.

2. Interview with Staff DD at the time of the tour completed on 06/23/16 revealed the lights in the path of egress from the lights between the 1st and 2nd floors in the stairwells to exit discharge are not tested by the facility.

3. Review of the emergency light testing completed on 06/23/16 revealed the battery operated emergency lights in the exit egress are not listed as being tested. This finding was verified by Staff S at the time of the documentation review.

38.2.10 Marking of Means of Egress.
Means of egress shall have signs in accordance with Section 7.10.

Based on observation and staff verification the facility failed to ensure lighted exit signage functioned appropriately in the exit egress path.

This has the potential to affect all patients receiving services at the facility.

Findings include:

During tour of the facility completed on 06/23/16 revealed the exit light above the East exit door on the first floor was not lit and failed to function when the test button was pushed. This finding was verified by Staff DD at the time of the observation.


Based on observation the facility failed to provide safe access to public way, as per NFPA 101 section 38.2.7 in accordance with section 7.7.1. This has the potential to affect all patients that receive services from the facility.


Findings include:

Tour of the facility conducted on 06/23/16 revealed an exit discharge at the east exit, exited to a 4 feet by 3 feet concrete pad then to a grass covered area with 12 inch stepping pavers encompassing a 40 foot distance to the parking area. This finding was verified by Staff DD at the time of the observation.

7-3.2* Testing.
Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

Based on observation, documentation review, and staff interview the facility failed to ensure Single Station Smoke Detectors were tested in accordance with NFPA 72. This has the potential to affect all patients receiving services from the facility.

Findings include:

1. During tour of the facility completed on 06/21/16 revealed single station smoke detectors throughout the facility.

2. During documentation review completed on 06/23/16 revealed no documentation of testing for the smoke detectors in the facility.

3. Interview with Staff S completed on 06/23/16 at 1:30 PM revealed the facility does not have documentation of the smoke detector testing for the facility.

Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 50 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 300 or more total occupants.


Based on observation, documentation review, and staff interview the facility failed to ensure battery operated lighting in the exit egress functioned appropriately and were tested monthly and annually as per NFPA 101. This has the potential to affect all patients receiving services at the facility.

Findings include:

1. During tour of the facility completed on 06/23/16 revealed the emergency lighting located in the two exit egress paths. This finding was verified by Staff DD at the time of the observation.

2. Interview with Staff DD at the time of the tour completed on 06/23/16 revealed the lights in the path of egress after leaving the entrance to the facility's entrance was not tested.

3. Review of the emergency light testing completed on 06/23/16 revealed the battery operated emergency lights in the exit egress are not listed as being tested. This finding was verified by Staff S at the time of the documentation review.