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Based on facility tour and staff interview and verification, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. This had the potential to affect all those who utilized this area of the facility. The facility had a capacity of 99 patient beds with a census of 23 patients at the time of the survey completed on 03/19/15.

Findings included:

On 03/17/15, between 9:00 A. M. and 4:00 PM., tour of the facility was conducted with facility staff TT, UU, VV and WW. The following observations of corridor walls were noted, regarding failure to extend corridor walls to the decking above in non-sprinkler protected areas;

1. Located on level 2, south corridor, observation above the ceiling tiles in the corridor outside the waiting room, revealed a large open area where the corridor wall did not extend to the floor decking above.

2. Located in the same level 2 south corridor, near exam room 1, observation above the ceiling tiles revealed an area approximated at least six feet in length where the corridor wall did not extend to the floor decking above.

3. Located on level 1, observation above the ceiling tiles near X-ray rooms A, B and C, revealed the corridor walls did not extend to the floor decking above in an area approximated at least 18 feet in length.

4. Observation above the ceiling tiles of the same corridor on level 1 near the lab storage area revealed the corridor wall did not extend to the floor decking above for approximately 30 feet.

5. Observation above the ceiling tiles of the same corridor on level 1 between the lab, chemistry lab and break room revealed the corridor wall did not extend to the floor decking above.

6. Observation above the ceiling tiles in the level 1 corridor near the nursing office revealed an annular space surrounding a drain line that extended through the wall.


7. Observation above the ceiling tiles of the corridor wall from inside the staff breakroom on level 1 revealed two, one inch penetrations and one, three inch penetration.


Staff present on the tour confirmed the corridor walls did not extend to the decking above at the non-sprinklered portions on level 1 and 2 of the building. Additionally staff present on tour confirmed the space above the lab ceiling was used as an air plenum.

Based on facility tour and staff confirmation it was determined this facility failed to ensure all doors protecting corridor openings were maintained in a manner in which there was no impediments to the closing of the door. This had the potential to affect all those who utilized this area of the facility. The facility had a capacity of 99 patient beds with a census of 23 patients at the time of the survey completed on 03/19/15.

Findings included:

On 03/16/15 between 2:00 P.M. and 4:00 P.M., tour of level 3 of the facility was conducted with facility Staff TT, UU, VV and WW. Observation of patient room 330 revealed the door had an automatic closing device which would function then the fire alarm was activated. When the door was tested by releasing the hold, the door was unable to close and latch due to the cubicle curtain hanging within the path of the door swing area.

On 03/18/15 at 9:55 A.M., observation of additional patient room doors with Staff TT revealed that rooms 331, 333 and 334, failed to close and latch due to the cubicle curtains hanging within the path of the door swing area. Staff TT confirmed the cubicle curtains in the patient rooms needed to be moved or repaired to allow for the doors close and latch.

2. Observation of level 1 sliding glass doors at the entrance of the emergency room treatment areas during all days of the survey, revealed the sliding glass doors had no mechanism in place that permitted the doors to securely latch. Interview of Staff TT, UU and VV on 03/17/15 and 03/18/15 confirmed the facility was aware the doors did not securely latch and that new doors had been ordered for the emergency treatment area.

Based on facility tour and staff confirmation it was determined this facility failed to ensure vision panels in corridor doors were fixed window assemblies in approved frames. This had the potential to affect all those who utilized this area of the facility. The facility had a capacity of 99 patient beds with a census of 23 patients at the time of the survey completed on 03/19/15.

Findings included:

On 03/17/15 between 1:35 P.M. and 3:00 P.M., observation of level 1, gift shop, was conducted with Staff TT, UU and WW. Observation of the gift shop revealed an area approximately 10 feet wide by 20 feet in length and was not provided automatic sprinkler protection. Two doors opened into two separate exit egress corridors with no automatic sprinkler protection in the corridors.

Observation of the door opening into an exit corridor, closest to the main entrance doors, revealed the door was largely constructed of glass surrounded by a non-fire rated wood frame. When the gift shop was open, the door was unlocked and had no mechanism in place to ensure secure latching. Observation of the door when the gift shop was closed revealed the door was locked.

Staff present on tour confirmed the observations.

Based on review of the facility schematic, facility tour and staff confirmation it was determined the facility failed to ensure smoke barriers were constructed to provide at least a one half hour fire resistance rating and were constructed in accordance with 8.3. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 99 patient beds with a census of 23 patients at the time of the survey completed on 03/19/15.

Findings included:

On 03/17/15, between 9:00 A.M. and 11:00 A.M., observation of level 2 south corridor was conducted with Staff TT, UU, VV and WW. Observation of the facility schematic revealed the presence of a one hour fire rated smoke barrier wall which extended across a corridor to a leased office space known as the "Acuity" office. Observation of the one hour fire rated barrier wall, above the ceiling tiles, revealed a penetration surrounding duct work near the door of the leased office space. Staff WW present on tour confirmed the observation.

Based on review of the facility schematic, facility tour and staff confirmation it was determined the facility failed to ensure door openings in smoke barriers had at least a 20-minute fire protection rating or were at least 1¾-inch thick solid bonded wood core. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 99 patient beds with a census of 23 patients at the time of the survey completed on 03/19/15.

Findings included:

On 03/17/15, between 9:00 A.M. and 11:00 A.M., observation of level 2 south corridor was conducted with Staff TT, UU, VV and WW. Observation of the facility schematic revealed the presence of a one hour fire rated smoke barrier wall near the "cat scan" office and the "Acuity" office.

Observation of the corridor where the smoke barrier was designated to be located revealed there were no doors present in the corridor opening of the smoke barrier wall. Staff present on tour confirmed the wall was a one hour fire rated barrier wall and confirmed there were no doors present in the corridor opening.

Further observation of the one hour fire rated smoke barrier wall revealed it continued into an office area. The door opening in the smoke barrier wall was to a leased office for another provider in the facility. The door to the office was observed to be a non-fire rated wood door with a large panel of non-fire rated glass in the upper half of the door.

Staff present on tour confirmed the wood door had no fire resistance rating for the wood or glass panel.

Based on review of facility schematics, facility observation and staff verification, the facility failed to ensure that one hour fire rated construction (with ¾ 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 was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 99 patient beds with a census of 23 patients at the time of the survey completed on 03/19/15.

Findings included:

On 03/16/15, between 1:00 P.M., and 4:00 P.M., and 03/17/15 between 9:00 A.M. and 4:30 P.M., tour of the facility was conducted with Staff TT, UU, VV and WW. Review of the facility schematic for placement of the automatic sprinkler system as well as the construction of hazardous areas throughout the facility was completed. The following areas designated as ordinary hazardous areas were observed with no automatic sprinkler protection in place.

1. Located on the fourth floor of the facility, a soiled utility room, with a non- fire rated wood door.

2. Located on level 2, a paint room, with a fire rated door and no self-closing device on the door.

3. Located on level 2, south, across from the "Cat Scan" room, a furnace room with two breaker boxes was observed with Staff TT. The door to the room had no fire resistance rating and no self-closing device. Observation above the ceiling tiles revealed conduit through the wall with unsealed annular space surrounding the conduit. A vent was observed to go through the corridor side of the wall into the furnace room. No damper was present and staff present on the tour confirmed the vent was a cold air return to the room. The schematic did not identify the room with one hour fire resistance construction.

4. Located on level 1, a lab storage room, with at least four shelves, approximately 10 feet in length where old x-ray files were stored. The lab also maintained storage of biohazard materials in the room. There was no noted one hour fire rated construction identified on the schematic. Observation above the ceiling tiles from the corridor side of the storage room revealed there was no one hour fire rated construction.

5. Observation above the ceiling tiles of the same corridor on level 1 between the lab, chemistry lab and break room revealed the lab wall did not provide for one hour fire rated construction surrounding the lab. Staff present on the tour confirmed the corridor walls did not extend to the decking above. Additionally staff present on tour confirmed the space above the lab ceiling was used as an air plenum.

6. Located on level M, a medical record storage room was observed. The room contained a significant amount of combustible files. Observation of the room revealed there were two doors. One door opened into a corridor and the other door opened into a connecting office. The door which opened into the corridor was a non-fire rated wood door with non-fire rated glass in the top half of the door. The other door which opened into an adjoining office space had no self-closing device.

Staff present on tour confirmed the observations and findings.

Based on review of the facility schematic, facility observation and staff interview and confirmation, the facility failed to meet the requirements for gift shops considered as non-hazardous in regard to having fire rated walls or sprinklers. This had the potential to affect all those who utilized this area of the facility. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 99 patient beds with a census of 23 patients at the time of the survey completed on 03/19/15.

Findings included:

On 03/17/15, between 9:00 A.M., and 4:00 P.M., tour of the facility was conducted with facility staff TT, UU, VV and WW. Observation of the gift shop, located on level 1, near the main entrance of the facility, revealed a shop approximately 10 feet wide and 20 feet in length. Observation of the items on display revealed the shop was not congested and did not have quantities of items considered to be hazardous. The gift shop flooring was carpet. The shop did not have automatic sprinkler protection.

Review of the facility schematic revealed the gift shop was not separated by fire rated construction. Observation above the ceiling tiles on the corridor side of two walls of the gift shop confirmed the non-fire rated construction. Staff present on tour confirmed that area of the facility was not provided automatic sprinkler protection.

Staff present on tour confirmed the observation.

Based on facility observation, staff interview and confirmation, the facility failed to ensure that stairways and smoke proof towers used as exits were in accordance with 7.2 with regard to access controlled egress doors. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 99 patient beds with a census of 23 patients at the time of the survey completed on 03/19/15.

Findings include;

On 03/16/15, between 1:00 P.M. and 2:00 P.M., tour of the level 4 locked behavioral unit was conducted with Staff TT and VV. Observation of the locked unit revealed the presence of three locked exit doors, two leading to stairwells and the third to the main entrance which lead to a corridor. Interview of Staff TT revealed the exit doors were locked due to the clinical needs of patients unless the fire alarm was activated then the exit doors were to unlock. Staff on the unit also had keys to the doors.

On 03/18/15, at 3:00 P.M. a test of the fire alarm system for the release of the three locked exit egress doors on the behavioral unit was conducted with Staff TT, VV, UU, XX and YY present. Observation of the stairwell door located at the end of the unit, closest to patient room 402, revealed it did not release upon activation of the fire alarm. The observation was confirmed by Staff TT, XX and YY.

Interview of Staff TT revealed the exit doors were periodically checked for release during fire drills but no supportive documentation of the testing was available. Staff TT confirmed the exit stairwell door had malfunctioned and did not release. A contracted fire alarm testing company was contacted immediately to initiate repairs.

Staff on the unit was informed the exit stairwell did not release as required and it was re-enforced to staff to have keys with them at all times.

On 03/19/15, at 9:00 A.M. the contracted fire alarm service was present for repairs to the lock on behavioral unit exit egress door. Repair was completed and testing was conducted by 11:00 A.M.

Additionally, observation of the exit doors, located at the entrance of the behavioral unit was conducted. At the time of the fire alarm test, the door in the path of egress did not open. The locking mechanism was noted to be on the door leading into the unit. That lock did release and staff present held the door open. Staff UU was present at the observation and confirmed the locking mechanism for the doors was on the door leading into the unit and not on the door in the path of egress.

Based on facility observation and staff interview and confirmation, the facility failed to ensure that exit access was arranged so that exits were readily accessible at all times in accordance with 7.1. The facility had a capacity of 99 patient beds with a census of 23 patients at the time of the survey completed on 03/19/15.

Findings include;

On 03/17/15, between 1:35 P.M. and 3:30 P.M., tour of level 1, x-ray area was conducted with Staff TT, VV and WW. Observation of a designated exit egress revealed the path lead to an exit discharge located within x-ray room A.

Observation of the exit discharge from outside the building revealed the door opened to a cemented area, covered with rocks, broken bricks and other debris. From the cemented area, steps lead to another cement pad at grade. Located on the cement pad was a garden hose folded in circles and above the hose was a window where an air conditioner was located.

Further observation of the path of egress revealed that travel had to continue on a steeply sloped, grassy, area, approximately 50 feet to another concrete pad which lead to the public way.

Staff WW present at the observation confirmed the circled hose and window air conditioner was in the path of egress once at grade level. Staff further confirmed the grassy sloped area was not conducive for persons in wheelchairs or with ambulation difficulties.

Based on facility observation and staff interview and confirmation, the facility failed to ensure that exit directional signs were displayed in accordance with 7.10. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 99 patient beds with a census of 23 patients at the time of the survey completed on 03/19/15.

Findings include;

On 03/16/15, between 1:35 P.M. and 4:00 P.M. and on 03/17/15, between 9:00 A.M. and 4:00 P.M., tour of the facility was conducted with Staff TT, UU, VV and WW. During tour of the facility exit directional signs were noted. The following exit signs failed to provide appropriate direction;

1. An exit sign located outside the locked behavioral unit, located on level 4, was visible from a waiting area located across the corridor from the locked unit. The exit sign pointed to another locked door which leads to a corridor and an exit stairwell. The locked door could not be opened without a key and was not designed to open with activation of the fire alarm system.

2. Located on level 3 north, an exit sign placed at the entrance of the rehabilitation unit pointed to the direction of two small rooms. The rooms did not lead to exit. Staff TT present at the observation confirmed the directional arrow on the sign was misleading.

3. An exit sign, located on level 1, outside x-ray room A, gave direction to the exit through the x-ray procedure room. Staff UU present at the observation confirmed the exit directional sign was not intended to lead persons into a procedure room in order to exit.


On 03/19/15 at 3:00 P.M., Staff UU revealed the exit signs had been changed to reflect more accurate direction.

Based on facility observation 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. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 99 patient beds with a census of 23 patients at the time of the survey completed on 03/19/15.

Findings include;

1. On 03/16/15 at 2:00 P.M. tour of level 4 operating room area was conducted with Staff TT, UU and VV. Observation of the operating room area revealed the presence of a medical gas storage area and manifold. The room contained three, H size cylinders of nitrous oxide, three H size cylinders of oxygen and one H size cylinder of carbon dioxide. Observation of the room revealed the door to the room was wood with no fire resistance rating noted on the door.

2. Observation on 03/17/15 at 1:35 P.M. of a level 2 medical gas storage area with Staff TT and WW revealed storage of medical gases greater than 3000 cubic foot. Observation of the med gas storage room revealed there were no vent to the exterior (outside) and no fire resistance rating on the door to the room.

Staff present during the observation confirmed the findings.

Based on facility observation and staff interview and verification, the facility failed to ensure that hazardous areas including, but not limited to, areas used for general storage, furnace rooms, and maintenance shops were protected in accordance with Section 8.4. Potentially any person utilizing the facility services could be affected.

Findings include.

On 03/18.15 between 10:40 A.M. and 2:25 P.M., tour of the offsite location was conducted with Staff TT and VV. The following hazardous areas were observed throughout the facility:

Second Floor

1. Observation was noted of a medical record storage area with a significant amount of combustible files. Staff present stated the files were from the physician offices located on that floor of the building. Observation of the non-sprinklered room revealed no fire resistance rating on the door to the room and no self-closing device on the door. Staff present on tour confirmed the storage area was not separated by one hour fire rated construction.

2. Observation of a small room designated as a linen closet revealed two electrical breaker boxes within the room. Located on shelves approximately 40 inches from the breaker boxes was storage of paper exam table covers and patient drapes. Staff present on tour confirmed the storage area was not separated by one hour fire rated construction. The door to the room had no self-closing device in place.

3. Observation of a mechanical room revealed the door to the room had a painted tab that typically noted the fire resistance rating for the door. The fire resistance rating was not visible. Additionally the door had no self-closing device in place. Staff present on tour confirmed the storage area was not separated by one hour fire rated construction.


First Floor
4. Observation of an x-ray storage area revealed a significant amount of stored x-ray files. Staff present on tour confirmed the storage area was not separated by one hour fire rated construction. The door to the room had no self-closing device in place.

Basement

5. Observation of a storage area designated for use by a leased tenant contained combustible items such as cardboard, paper files and nursing supplies. Staff present on tour confirmed the storage area was not separated by one hour fire rated construction. Observation of the door to the room revealed a three hour fire resistance rating but no self-closing device.

6. Observation of a large block storage room revealed such items as a hospital baby crib and exam tables. Observation of the door to the storage area revealed no fire resistance rating and no self-closing device on the door.

7. Observation of a medical record storage area revealed a room with two wood doors. The room contained a significant amount of combustible medical records in storage. Staff present on tour confirmed the storage area was not separated by one hour fire rated construction. One of the two doors had louvers in the lower third of the door which opened to the corridor. The other door had no fire resistance rating and no self-closing device.

8. A block mechanical room for the elevator motor was observed to have a door with a tab which typically noted the fire resistance rating of the door, painted over. The fire resistance could not be determined.

9. A storage room was noted with numerous cardboard boxes of pharmacy records. Staff present on tour confirmed the storage area was not separated by one hour fire rated construction. The combustible materials were stored in this room equipped with a wood door that had no fire resistance rating and no self-closing device,

10. Six smaller rooms enclosed in a very large block storage room contained a very significant amount of combustible files such as medical, financial and health records. The larger room also had an old anesthesia delivery machine in storage. The largest room contained shelves that were approximately 27 feet in length and had shelving at least six shelves high. These shelves were stacked with the combustible paper files and records. Observation at the top of the room revealed it was open with no separation between that room and the room next to it. The door to the room had no fire resistance rating.

Staff present at the observation confirmed the findings. The staff confirmed that most of the storage areas with ordinary hazardous materials did not meet the construction requirement for one hour fire rated separation.


Based on facility observation and staff interview and confirmation, the facility failed to ensure that access to exits was marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Potentially all persons utilizing the area could be affected.

Findings include;
On 03/18/15 observation of the physical therapy gym was conducted with Staff TT and UU. Observation revealed the gym was located in the basement of the building. Observation inside the gym revealed there were two doorways in the gym but no exit signs to show the way out. Staff present on tour confirmed the observation.