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Based on observation and interview, the facility did not provide a common separation wall with sealed wall penetrations. This deficiency occurred in 1 of the 4 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 7, 2015 at 11:42 am, observation revealed on the 1st floor floor in the CT control room, that a penetration was not sealed according to an approved method. The deficiency included a (2" X 8") brick removed for wires to pass through the 2 hour wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4; and 8.2.3.2.4.

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

Based on observation and interview, the facility did not provide and maintain the required building construction type with a compliant type of construction having support steel covered with rated fire proofing. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On April 6, 2015 at 10:55 am, observation revealed on the lower level floor in the laboratory, that the building's construction type was not compliant because the 'tent' above (enclosing) the lights in the rating ceiling tile was missing. This observed situation was not compliant with NFPA 101 (2000 ed.), Table 19.1.6.2.

2. On April 6, 2015 at 12:00 pm, observation revealed on the lower level floor in the Maintenance Office, that the building's construction type was not compliant because the plaster ceiling had a 8" X 8" hole in the 'rated' ceiling. This observed situation was not compliant with NFPA 101 (2000 ed.), Table 19.1.6.2.

3. On April 6, 2015 at 1:20 pm, observation revealed on the lower level floor in the boiler room tunnels, that the building's construction type was not compliant because there were holes in the ceiling (going to the floor above) and there was no fire caulk in the holes including the shower drains. This observed situation was not compliant with NFPA 101 (2000 ed.), Table 19.1.6.2.

4. On April 6, 2015 at 1:30 pm, observation revealed on the lower level floor in the boiler room tunnels, that fire proofing was missing from the structural steel beam at the access door to the tunnels. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2.

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

Based on observation and interview, the facility did not provide corridor separation doors with doors with positive-latching hardware. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On April 6, 2015 at 9:40 am, observation revealed on the lower level floor in the specially doctors suite, that the corridor door would not positively self-latch when pushed to a closed position. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.2. .

2. On April 7, 2015 at 9:53 am, observation revealed on the 1st floor floor in room 318, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2. .

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

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. This deficiency occurred in 2 of the 4 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 11:20 am, observation revealed on the lower level floor in the Respiratory Therapy area, that the smoke barrier wall was not compliant. The smoke barrier above the door going into the respiratory therapy did not go to the deck. Dry wall was missing. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Physical Plant Director).
______________________________________

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, doors held-open with the required safe guards, rated doors, and doors held-open with the required safe guards. This deficiency occurred in 3 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On April 6, 2015 at 10:38 am, observation revealed on the lower level floor in the blood draw, that the door would not self-close because there was no closer attached to the door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

2. On April 6, 2015 at 3:36 pm, observation revealed on the 1st floor floor in the x ray storage room, that the hazardous room door was prevented from self-closing by files cabinets' holding the door open. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

3. On April 7, 2015 at 1:34 pm, observation revealed on the 1st floor floor in the storage room, that the fire barrier door could not be verified to have the required rating. The fire door had clothes hooks screwed into the door with plastic slide board and clothes on the hooks. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

4. On April 7, 2015 at 1:45 pm, observation revealed on the 1st floor floor in the OR supply room, that the hazardous room door was prevented from self-closing by a permanent installed "flip up" stop at the bottom of the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

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

Based on observation and interview, the facility did not provide sufficient exit width capacity for the number of persons in the facility that included proper width of exits. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 9:50 am, observation revealed on the lower level floor in the exit door by the conference room, that the exit width was 36 inches. Patient exit doors are required to be 41.5 inches in the clear width from diagnostic and treatment areas. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5 and 7.3.

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

Based on observation and interview, the facility did not provide egress paths at all times with no obstructions in the path of egress, paths with sufficient headroom, and door hardware that operated with a single release motion. This deficiency occurred in 3 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On April 6, 2015 at 11:10 am, observation revealed on the lower level floor in the Respiratory Therapy, that the exit path was not readily accessible because equipment was 'piled' against the corridor exit door. In addition, the door into the other room was a bi-folding closet door, that did not swing open. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

2. On April 6, 2015 at 11:55 am, observation revealed on the lower level floor in the Maintenance Office, that the headroom was 6"8" for more than 2/3 of the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.5.

3. On April 7, 2015 at 2:36 pm, observation revealed on the 1st floor floor in the C - Section room, that the door release hardware required more than a single motion to release the door for exiting. There is a dead bolt on the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4. .

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

Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 10:10 am, observation revealed on the lower level floor in the rehab unit, that the facility was unable to verify that the lighting along the path of egress was powered from the emergency electrical system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1.

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

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 2:30 pm, observation and interview revealed on the lower level floor in the kitchen, that staff were not familiar with their responsibilities in the event of a fire, including what the K fire extinguisher was for and where the manual pull station for the grease hood was located. Staff L did not know what type of fire extinguisher was for grease fires and where the pull station for the kitchen hood suppression system is located. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.3. .

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Physical Plant Director).
______________________________________

Based on interview and a review of documents, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with compliant fire alarm testing. This deficiency occurred in 4 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 4:30 pm, record review and interview revealed that the fire alarm maintenance was not compliant. During a fire drill, the fire alarm horns are silenced in order to hear the non-fire alarm paging system. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-3.2.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff D (Physical Plant Director).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers located the appropriate distance apart. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 7, 2015 at 10:00 am, observation revealed on the 1st floor floor in the Med/surge nurse station, that a sprinkler was located nine feet from the wall. Sprinklers cannot be farther from each other than the maximum required separation distance of 15' for standard discharge heads or farther than 7-1/2' from a wall. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.3. .

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

Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have a complete annual inspection. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 2:50 pm, observation revealed on the lower level floor in the elevator equipment room, that the sprinkler system maintenance was not compliant. The Carbon Dioxide system (in stead of a sprinkler system) had not been maintained for years. Staff D (Physical Plant Director) was unsure that it even worked. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2. and Table 2-1.

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

Based on observation and interview, the facility did not provide and implement a policy on the use of portable space heating devices with space heaters that comply with code requirements. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 7, 2015 at 10:15 am, observation revealed on the 1st floor floor in the nursery work room, that a space heater was used that warmed the nursery. In addition, the space heaters can not be used in patient treatment areas including corridors used for rehab. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.8.

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

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with oxygen cylinders restrained from falling, and separation of oxygen from combustibles. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On April 6, 2015 at 10:28 am, observation revealed on the lower level floor in the rehabit unit, that cylinders of oxygen in storage were not secured to keep them from falling. A partially full oxygen tank was stored in the north east corner of the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), 8-3.1.11.

2. On April 7, 2015 at 1:16 pm, observation revealed on the 1st floor floor in the Nuclear Med, that combustible materials were stored too close to the storage site of cylinders of oxygen. The oxygen tank was next to a soiled linen cart. This observed situation was not compliant with NFPA 99 (1999 ed.), 4-3.1.1.2.

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

Based on observation and interview, the facility did not provide compliant medical gas piping as required by NFPA 99 by not clearly identifying zone shut off valves. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 3:55 pm, observation and interview revealed on the 1st floor in the Med/surge nurse station, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation had the medical gas zone valve incorrectly labeled, and staff CC did not know which rooms were shut off by the incorrectly labeled medical gas zone valve. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.4 and NFPA 99 (1999 ed.), Chap 4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Physical Plant Director) and staff CC (Nurse).

Based on observation and interview, the facility did not provide a code compliant environment with suite travel distance under the required limits. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 3:38 pm, observation revealed on the 1st floor floor in the x ray storage room, that the travel distance through two intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. The travel distance is 56 feet to a corridor door. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.5.8.

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

Based on observation and interview, the facility did not provide a Type I essential electrical system that was divided with three branches in accordance with the codes with a compliant type 1 emergency electrical system. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 10:48 am, observation revealed on the lower level floor in the laboratory, that the type 1 emergency electrical system did not comply with code. The Bact Alert 3D machine was plugged into the life safety circuit. It should be plugged into another (critical or equipment) circuit. This observed situation was not compliant with NFPA 99 (1999 ed.) 3-4.2.2.2.

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

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords, working clearances at electrical panels, closed electrical raceways, proper use of extension cords, and working clearances at electrical panels. This deficiency occurred in 3 of the 4 smoke compartments and had the potential to affect all inpatients, outpatients,staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On April 6, 2015 at 11:50 am,observation revealed on the lower level floor in the Maintenance Office, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to various items in the office. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

2. On April 6, 2015 at 2:12 pm, observation revealed on the lower level floor in the kitchen, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a radio, and a second cord was used to supply power to the microwave and other kitchen appliances. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

3. On April 6, 2015 at 2:20 pm, observation revealed on the lower level floor in the kitchen, that access to electrical panel was less than 3'-0" clearance. A fryer was in front of a electrical disconnect. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

4. On April 6, 2015 at 2:47 pm, observation revealed on the lower level floor in the elevator equipment room, that a knock-out was open in an electrical box. In addition, the electrical box was not securely mounted. This observed situation was not compliant with NFPA 70 (1999 ed.), 517-12.

5. On April 7, 2015 at 9:30 am, observation revealed on the 1st floor in room 306 & 323, that the electrical code was not followed. Cords where plugged into the wall in one room and the equipment was located in a different room. The electrical cord passed through the doorway. This observed situation was not compliant with NFPA 70 (1999 ed.).

6. On April 7, 2015 at 2:00 pm, observation revealed on the 1st floor in the OR equipment room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to medical equipment to maintain a battery charge. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8.

7. On April 7, 2015 at 2:05 pm, observation revealed on the 1st floor in the OR equipment room, that clearance in front of the electrical equipment was less than 3'-0". There was no access to the panel. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26. .

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Physical Plant Director).
______________________________________

Based on observation and interview, the facility did not provide a common separation wall with sealed wall penetrations. This deficiency occurred in 1 of the 4 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 7, 2015 at 11:42 am, observation revealed on the 1st floor floor in the CT control room, that a penetration was not sealed according to an approved method. The deficiency included a (2" X 8") brick removed for wires to pass through the 2 hour wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4; and 8.2.3.2.4.

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

Based on observation and interview, the facility did not provide and maintain the required building construction type with a compliant type of construction having support steel covered with rated fire proofing. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On April 6, 2015 at 10:55 am, observation revealed on the lower level floor in the laboratory, that the building's construction type was not compliant because the 'tent' above (enclosing) the lights in the rating ceiling tile was missing. This observed situation was not compliant with NFPA 101 (2000 ed.), Table 19.1.6.2.

2. On April 6, 2015 at 12:00 pm, observation revealed on the lower level floor in the Maintenance Office, that the building's construction type was not compliant because the plaster ceiling had a 8" X 8" hole in the 'rated' ceiling. This observed situation was not compliant with NFPA 101 (2000 ed.), Table 19.1.6.2.

3. On April 6, 2015 at 1:20 pm, observation revealed on the lower level floor in the boiler room tunnels, that the building's construction type was not compliant because there were holes in the ceiling (going to the floor above) and there was no fire caulk in the holes including the shower drains. This observed situation was not compliant with NFPA 101 (2000 ed.), Table 19.1.6.2.

4. On April 6, 2015 at 1:30 pm, observation revealed on the lower level floor in the boiler room tunnels, that fire proofing was missing from the structural steel beam at the access door to the tunnels. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2.

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

Based on observation and interview, the facility did not provide corridor separation doors with doors with positive-latching hardware. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On April 6, 2015 at 9:40 am, observation revealed on the lower level floor in the specially doctors suite, that the corridor door would not positively self-latch when pushed to a closed position. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.2. .

2. On April 7, 2015 at 9:53 am, observation revealed on the 1st floor floor in room 318, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2. .

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

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. This deficiency occurred in 2 of the 4 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 11:20 am, observation revealed on the lower level floor in the Respiratory Therapy area, that the smoke barrier wall was not compliant. The smoke barrier above the door going into the respiratory therapy did not go to the deck. Dry wall was missing. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Physical Plant Director).
______________________________________

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, doors held-open with the required safe guards, rated doors, and doors held-open with the required safe guards. This deficiency occurred in 3 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On April 6, 2015 at 10:38 am, observation revealed on the lower level floor in the blood draw, that the door would not self-close because there was no closer attached to the door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1 and 8.4.1.

2. On April 6, 2015 at 3:36 pm, observation revealed on the 1st floor floor in the x ray storage room, that the hazardous room door was prevented from self-closing by files cabinets' holding the door open. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

3. On April 7, 2015 at 1:34 pm, observation revealed on the 1st floor floor in the storage room, that the fire barrier door could not be verified to have the required rating. The fire door had clothes hooks screwed into the door with plastic slide board and clothes on the hooks. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

4. On April 7, 2015 at 1:45 pm, observation revealed on the 1st floor floor in the OR supply room, that the hazardous room door was prevented from self-closing by a permanent installed "flip up" stop at the bottom of the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

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

Based on observation and interview, the facility did not provide sufficient exit width capacity for the number of persons in the facility that included proper width of exits. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 9:50 am, observation revealed on the lower level floor in the exit door by the conference room, that the exit width was 36 inches. Patient exit doors are required to be 41.5 inches in the clear width from diagnostic and treatment areas. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5 and 7.3.

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

Based on observation and interview, the facility did not provide egress paths at all times with no obstructions in the path of egress, paths with sufficient headroom, and door hardware that operated with a single release motion. This deficiency occurred in 3 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On April 6, 2015 at 11:10 am, observation revealed on the lower level floor in the Respiratory Therapy, that the exit path was not readily accessible because equipment was 'piled' against the corridor exit door. In addition, the door into the other room was a bi-folding closet door, that did not swing open. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

2. On April 6, 2015 at 11:55 am, observation revealed on the lower level floor in the Maintenance Office, that the headroom was 6"8" for more than 2/3 of the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.5.

3. On April 7, 2015 at 2:36 pm, observation revealed on the 1st floor floor in the C - Section room, that the door release hardware required more than a single motion to release the door for exiting. There is a dead bolt on the door. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4. .

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

Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 10:10 am, observation revealed on the lower level floor in the rehab unit, that the facility was unable to verify that the lighting along the path of egress was powered from the emergency electrical system. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1.

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

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 2:30 pm, observation and interview revealed on the lower level floor in the kitchen, that staff were not familiar with their responsibilities in the event of a fire, including what the K fire extinguisher was for and where the manual pull station for the grease hood was located. Staff L did not know what type of fire extinguisher was for grease fires and where the pull station for the kitchen hood suppression system is located. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.3. .

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Physical Plant Director).
______________________________________

Based on interview and a review of documents, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with compliant fire alarm testing. This deficiency occurred in 4 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 4:30 pm, record review and interview revealed that the fire alarm maintenance was not compliant. During a fire drill, the fire alarm horns are silenced in order to hear the non-fire alarm paging system. This situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.7 and NFPA 72 (1999 ed.), Chapter 7-3.2.

This condition was confirmed at the time of discovery by a concurrent record review and interview with staff D (Physical Plant Director).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers located the appropriate distance apart. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 7, 2015 at 10:00 am, observation revealed on the 1st floor floor in the Med/surge nurse station, that a sprinkler was located nine feet from the wall. Sprinklers cannot be farther from each other than the maximum required separation distance of 15' for standard discharge heads or farther than 7-1/2' from a wall. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.3. .

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

Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have a complete annual inspection. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 2:50 pm, observation revealed on the lower level floor in the elevator equipment room, that the sprinkler system maintenance was not compliant. The Carbon Dioxide system (in stead of a sprinkler system) had not been maintained for years. Staff D (Physical Plant Director) was unsure that it even worked. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2. and Table 2-1.

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

Based on observation and interview, the facility did not provide and implement a policy on the use of portable space heating devices with space heaters that comply with code requirements. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 7, 2015 at 10:15 am, observation revealed on the 1st floor floor in the nursery work room, that a space heater was used that warmed the nursery. In addition, the space heaters can not be used in patient treatment areas including corridors used for rehab. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.8.

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

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with oxygen cylinders restrained from falling, and separation of oxygen from combustibles. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On April 6, 2015 at 10:28 am, observation revealed on the lower level floor in the rehabit unit, that cylinders of oxygen in storage were not secured to keep them from falling. A partially full oxygen tank was stored in the north east corner of the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), 8-3.1.11.

2. On April 7, 2015 at 1:16 pm, observation revealed on the 1st floor floor in the Nuclear Med, that combustible materials were stored too close to the storage site of cylinders of oxygen. The oxygen tank was next to a soiled linen cart. This observed situation was not compliant with NFPA 99 (1999 ed.), 4-3.1.1.2.

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

Based on observation and interview, the facility did not provide compliant medical gas piping as required by NFPA 99 by not clearly identifying zone shut off valves. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 3:55 pm, observation and interview revealed on the 1st floor in the Med/surge nurse station, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation had the medical gas zone valve incorrectly labeled, and staff CC did not know which rooms were shut off by the incorrectly labeled medical gas zone valve. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.4 and NFPA 99 (1999 ed.), Chap 4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Physical Plant Director) and staff CC (Nurse).

Based on observation and interview, the facility did not provide a code compliant environment with suite travel distance under the required limits. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 3:38 pm, observation revealed on the 1st floor floor in the x ray storage room, that the travel distance through two intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. The travel distance is 56 feet to a corridor door. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.5.8.

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

Based on observation and interview, the facility did not provide a Type I essential electrical system that was divided with three branches in accordance with the codes with a compliant type 1 emergency electrical system. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On April 6, 2015 at 10:48 am, observation revealed on the lower level floor in the laboratory, that the type 1 emergency electrical system did not comply with code. The Bact Alert 3D machine was plugged into the life safety circuit. It should be plugged into another (critical or equipment) circuit. This observed situation was not compliant with NFPA 99 (1999 ed.) 3-4.2.2.2.

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

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords, working clearances at electrical panels, closed electrical raceways, proper use of extension cords, and working clearances at electrical panels. This deficiency occurred in 3 of the 4 smoke compartments and had the potential to affect all inpatients, outpatients,staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On April 6, 2015 at 11:50 am,observation revealed on the lower level floor in the Maintenance Office, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to various items in the office. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

2. On April 6, 2015 at 2:12 pm, observation revealed on the lower level floor in the kitchen, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a radio, and a second cord was used to supply power to the microwave and other kitchen appliances. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

3. On April 6, 2015 at 2:20 pm, observation revealed on the lower level floor in the kitchen, that access to electrical panel was less than 3'-0" clearance. A fryer was in front of a electrical disconnect. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

4. On April 6, 2015 at 2:47 pm, observation revealed on the lower level floor in the elevator equipment room, that a knock-out was open in an electrical box. In addition, the electrical box was not securely mounted. This observed situation was not compliant with NFPA 70 (1999 ed.), 517-12.

5. On April 7, 2015 at 9:30 am, observation revealed on the 1st floor in room 306 & 323, that the electrical code was not followed. Cords where plugged into the wall in one room and the equipment was located in a different room. The electrical cord passed through the doorway. This observed situation was not compliant with NFPA 70 (1999 ed.).

6. On April 7, 2015 at 2:00 pm, observation revealed on the 1st floor in the OR equipment room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to medical equipment to maintain a battery charge. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8.

7. On April 7, 2015 at 2:05 pm, observation revealed on the 1st floor in the OR equipment room, that clearance in front of the electrical equipment was less than 3'-0". There was no access to the panel. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26. .

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