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Based on 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 May 27, 2015, the facility verified that the penetration on the 1st floor in the CT control room was not fixed. The deficiency included a (2" X 8") brick removed for wires to pass through the 2 hour wall. This 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 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 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

3. On May 27, 2015, the facility verified that 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 May 27, 2015, the facility verified that 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 and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction. 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 May 27, 2015, the facility verified that 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 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

3. On May 27, 2015, the facility verified that 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 May 27, 2015, the facility verified that 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 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 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

2. On May 27, 2015, the facility verified that 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 May 27, 2015, the facility verified that 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 May 27, 2015, the facility verified that 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 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 May 27, 2015, the facility verified 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).
Note: Waiver Requested

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 May 27, 2015, the facility verified that 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 May 27, 2015, the facility verified that 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 May 27, 2015, the facility verified that 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 May 27, 2015, the facility verified that 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 May 27, 2015, the facility verified that 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.

6. On May 27, 2015, the facility verified that 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.

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