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Based on observation and interview, the facility did not provide and maintain the required building construction type with sealed floor penetrations. This deficiency occurred in 2 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 12/1/2014 at 2:40 pm, observation revealed on the 1st floor in the oxygen storage room, that there were penetrations through the floor that were not fire stopped according to an approved method. The deficiency included pipes through the ceiling. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

2. On 12/2/2014 at 7:45 am, observation revealed on the 3rd floor in the toilet room 354, that there was a penetration through the floor that was not fire stopped according to an approved method. The deficiency included the pipe where the toilet used to be. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with rooms open to the corridor with the required safe-guards. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 12/2/2014 at 9:08 am, observation revealed on the 4th floor in the area in front of room 403, which is open to the corridor, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The corridor smoke detector did not cover the alcove because of the 18 inch header. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1 .

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware and doors that close when pushed or pulled. This deficiency occurred in 9 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 12/1/2014 at 11:50 am, observation revealed on the 2nd floor in the room 260, 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.), 18.3.6.3.2.

2. On 12/1/2014 at 2:56 pm, observation revealed on the 1st floor that the dining room door to the corridor was held open with a hand sanitizer stand. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated walls that had properly installed fire dampers, rated wall construction, and rated doors. This deficiency occurred in 4 of the 11 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 12/1/2014 at 1:59 pm, observation revealed on the 2nd floor in the the shaft room 280, that the shaft enclosure wall was not constructed to have a 2-hour fire resistance rating because the cinder block had holes in it, a steel pipe was imbedded in the cinder block wall, the spring was missing from the access panel door and wood was installed as a backer around the rated access panel door frame. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.

2. On 12/1/2014 at 2:10 pm, observation revealed on the 2nd floor in the room 224.1, that one or more air ducts penetrated the shaft enclosure and could not be confirmed to have a properly installed fire damper. The duct was missing flanges on each side of the rated wall. This observed situation was not compliant with NFPA 90A (1999 ed.), 3-3.4.

3. On 12/2/2014 at 7:30 am, observation revealed on the 3rd floor in the electrical room 383, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the cinder block had holes in it. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.

4. On 12/2/2014 at 7:34 am, observation revealed on the 3rd floor in the electrical room 383, that the door in the vertical shaft wall could not be verified of having the required rating. The spring to close the door was unattached. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.1.1, and 8.2.5.4, and 8.2.3.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent, that "no-exit" signs are required at doors that may be confused as exits, and non-egress pathways without exit signs. This deficiency occurred in 11 of the smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 12/2/2014 at 7:10 am, observation revealed on the1st floor in the main entrance/exit lobby/vestibule, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near the exit/vestibule lobby. At night 2 of the 3 doors are turned off and there is no exit sign for the door that is operational.This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4.

2. On 12/2/2014 at 7:15 am, observation revealed on the 1st floor in the main entrance/exit lobby/vestibule, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. At night 2 of the 3 exit doors are locked and there is no exit sign on the 2 doors that are not operational. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.8.1.

3. On 12/2/2014 at 9:26 am, observation revealed on the 4th floor in the corridor to the ICU suite, that an exit sign was installed at a location that the facility confirmed was not an exit. There is an exit sign from the corridor into the ICU suite. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency occurred in 4 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

2. On 12/1/2014 at 2:21 pm, observation revealed on the 2nd floor in the smoke barrier wall by room 250, that penetrations were not sealed according to an approved method. The deficiency included a 2 inch water pipe. On 2/3/2015 at 4:20 PM observation revealed on the 2nd floor in the smoke barrier wall by staff bathroom on the back side of room 250, that penetrations were not sealed according to an approved method. The deficiency included a 1 1/4 inch water pipe. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

This condition was originally confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations). The drain pipe on the backside of the smoke barrier wall (staff bathroom) was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), and staff B (CEO).


DONE

Based on observation and interview,the facility did not enclose hazardous rooms with closers on all doors and rated doors. This deficiency occurred in 11 of the 11 smoke compartments,and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 12/1/2014 at 1:10 pm, observation revealed on the 2nd floor in room 218, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. In addition, the walls were not 1 hour rated due to penetrations not being sealed. The room contained bins of clean linen, trash bins and other combustible material in quantities deemed hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 .

2. On 12/1/2014 at 1:15 pm, observation revealed on the 2nd floor in room 216, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. In addition, the walls were not 1 hour rated due to penetrations not being sealed. The room contained cleaning supplies and other combustible material in quantities deemed hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 .

3. On 12/1/2014 at 1:25 pm, observation revealed on the 2nd floor in the room 208, pharmacy, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. In addition, the walls were not 1 hour rated due to penetrations not being sealed. The room contained bins of drugs typically wrapped in plastic or foam and other combustible material in quantities deemed hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 .

4. On 12/1/2014 at 3:05 pm, observation revealed on the 1st floor in the room 153, CT equipment room, that the fire barrier door could not be verified to have the required rating. The room contained boxes of combustibles including Christmas decorations. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

5. On 12/1/2014 at 3:38 pm, observation revealed on the 1st floor in the storage by Administration, that the door would not self-close because there was no closer. 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.), 18.3.2.1 and 8.4.1.

6. On 12/1/2014 at 3:39 pm, observation revealed on the 1st floor in the room 120, storage admission records, that the door would not self-close because there was not closer. 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.), 18.3.2.1 and 8.4.1.

7. On 12/1/2014 at 3:45 pm, observation revealed on the 1st floor in the medical records, room 123, that the fire barrier door could not be verified to have the required rating. The door has coats hanging on it with a 'coat hanger' screwed into the fire door. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1.

8. On 12/2/2014 at 8:00 am, observation revealed on the 3rd floor in the room 327, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 .

9. On 12/2/2014 at 9:13 am, observation revealed on the 4th floor in the room 424, equipment storage room, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The access panel in the room are not rated. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 .

10. On 12/2/2014 at 9:57 am, observation revealed on the 4th floor in the room 426, clean equipment storage , that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 .

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).
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Based on observation and interview, the facility did not provide enclosures around exit stairs with rated wall construction. On 12/1/2014 at 11:35 am, observation revealed on the 1st floor in the stairwell 3 at the bottom, that the exit enclosure wall was not constructed to the required fire rating. The window enclosure at the bottom was not 2 hour rated. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4 and 8.2.3.2, and 7.1.3.2.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path and no obstructions in the path of egress. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 12/1/2014 at 11:32 am, observation revealed on the 1st floor in the electrical vault, that the door was locked from the egress side. A pad lock was installed at the exterior door and if in place, no one can exit. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.4.

2. On 12/1/2014 at 12:51 pm, observation revealed on the 2nd, 3rd and 4th floor, that the exit path was not readily accessible because the door from the toilet room can be in the open position and prevent the room door to the corridor being opened or closed. This applies to all patient rooms and all offices that previously were patient rooms throughout the hospital. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

3. On 12/1/2014 at 2:41 pm, observation revealed on the 1st floor in the closet to the oxygen storage room, that the exit path was not readily accessible because the door did not open 90 degrees. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. The proper width of corridors is 8' for patient areas. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.


FINDINGS INCLUDE:

On 12/1/2014 at 11:19 am, observation revealed on the 2nd floor in the corridor between room 268 and 272, that the clear and unobstructed width of the corridor was under 8 feet in width of the corridor because a copy machine was placed at the end of the corridor. This copy machine reduce the exit width out of the end rooms, 268 and 272 into the corridor to be less than 3 feet. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

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 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 12/1/2014 at 11:40 am, observation revealed on the 1st floor outside of stair 3, at the bottom, that the egress lighting was not compliant. The lights were metal halide that will not restrike immediate after a power outage, and takes several minutes to obtain full brightness. 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 E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation,record review and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies, the required quantity of drills,and documentation of the alarm transmission to a monitoring station during a fire drill. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 12/1/2014 at 5:20 pm, record review revealed that the facility fire drills were conducted in a pattern so they were not always at unexpected times. The day and night fire drills were conducted on the same day for the three quarters of 2014, i.e. 3/27, 6/30 and 10/4. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

2. On 12/1/2014 at 5:30 pm, record review revealed that the fire drills were not conducted quarterly on every shift. The third quarter was missed between June 30 and September 30, 2014 This situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

3. On 12/1/2014 at 5:35 pm, record review of the fire drill reports for the prior 12 months indicated that there was no documentation that the fire drills included the transmission of the fire alarm signal. In addition, there was no documentation that the second phone line worked. This situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

4. On 12/2/2014 at 6:45 am,during an actual observation of a fire drill on the 3rd floor North, Staff O partially closed, but did not latch, the doors to the patient rooms. The safety officer (Staff E) first pulled the fire alarm, then went to a staff room and told staff that there was fire in a computer in that room. The safety officer (Staff E), as an observer, then announced the fire location over the paging system, instead of staff doing it. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

This condition was confirmed at the time of discovery by a concurrent observation, record review and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with no wall obstructions, ceilings sealed above the sprinklers to collect heat, unobstructed water distribution, all rooms sprinkled when the code required full sprinkling, and non-sprinkled rooms that met permitted exceptions. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.


FINDING INCLUDE:

1. On 12/1/2014 at 11:28 am, observation revealed on the 2nd floor in room 274, that a wall obstructed the discharge of sprinkler water from reaching an unprotected area on the other side of the wall. The obstruction included a wall that created an alcove that contained a refrigerator below a microwave. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

2. On 12/1/2014 at 12:51 pm, observation revealed on the 2nd floor in room 224.1, that the ceiling did not provide a heat collection enclosure above the sprinkler and would permit heat to enter the void above the ceiling. As a result, the device would not operate with its designed response time. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

3. On 12/2/2014 at 8:25 am, observation revealed on the 3rd floor in room 310, that items were stored on a shelf within 18" below a sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.6.

4. On 12/2/2014 at 8:53 am, observation revealed on the 4th floor in the on call bathroom of room 418, that there was no sprinkler or approved alternative suppression measures. The building was required to be fully sprinkled because corridor walls are not 1 hour rated. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1 (exception).

5. On 12/2/2014 at 12:16 pm, observation revealed on the 1st floor in the electrical vault, that the room was not sprinkler protected, although the entire facility was required to be sprinkled to meet a construction exception. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but the following was not provided: a door closing devise was missing to ensure automatic closing and positive latching, a heat/smoke detector was missing within the room for early detection of a fire, the door was missing a label to verify it was rated for at least 90 minute, and an electrical cable through the rated wall was not fire stopped with an approved UL design system. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1 (exception).

6. On 12/2/2014 at 11:31 pm, observation revealed on the 1st floor in all the stair wells that sprinkler protection was not provided under the bottom of the stairs. The sprinkler head was not at the angle of the stairs, leaving floor space that was not protected. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1 (exception).


This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

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 sprinklers free of lint. This deficiency occurred in 4 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 12/1/2014 at 11:38 am, observation revealed on the 1st floor in the exterior walkway between stair 3 and the electrical vault, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

2. On 12/1/2014 at 1:27 pm, observation revealed on the 2nd floor in the room 208, pharmacy, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with compliant fire dampers, access to fire dampers, neutral airflow between the corridor and rooms, and ventilation systems that comply with NFPA 90A. This deficiency occurred in 11of the11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDING INCLUDE;

1 On 12/2/2014 at 12:15 pm, observation revealed on the 1st floor in the electrical vault, that a fire damper was not installed in an air duct that penetrated the rated wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 and NFPA 90A (1999 ed.), 3-3.1.

2. On 12/2/2014 at 1:00 pm, observation revealed that the space was not provided with compliant ventilation. It was observed that an induct smoke detector to shutdown the Roof top Unit #1 (air handler) and to close each floors supply smoke damper,to isolate the air handler,could not be verified.This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.).

3. On 12/2/2014 at 1:05 pm, observation revealed that the space was not provided with compliant ventilation. It was observed that an in-duct smoke detector to shutdown the Roof top Unit #3 (air handler) could not be verified. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation and interview, the facility did not provide a compliant kitchen extinguishing system as required by NFPA 96. The range hoods were not cleaned semi-annually. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.


FINDINGS INCLUDE:

On 12/2/2014 at 11:05 am, observation revealed that a label was not installed on the surface of the hood or elsewhere in the kitchen that showed the date of the last cleaning. This observed situation was not compliant with NFPA 96 (1998 ed.), 8-3.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on interview and observation, the facility did not provide hanging drapes or curtains that met code requirements, such as flammability or sprinkler obstruction with cubical curtains that permit the designed distribution of sprinkler water. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 12/1/2014 at 1:43 pm, observation revealed on the 2nd floor in the shower room, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.5 and NFPA 13 (1999 ed.) 5-6.5.2.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash. This deficiency occurred in 3 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 12/1/2014 at 3:00 pm, observation revealed on the 1st floor in the dinning room, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Two 40 gallon garbage containers and a recycle container were located next to each other. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

2. On 12/2/2014 at 7:50 am, observation revealed on the 3rd floor in the 3rd floor staff lounge, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. A 40 gallon recycling bin was located in the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

3. On 12/2/2014 at 7:55 am, observation revealed on the 3rd floor in the restroom off of the staff lounge of the 3rd floor, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. A 60 gallon trash bin was located in the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

4. On 12/2/2014 at 8:40 am, observation revealed on the 3rd floor in the dialysis, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There were trash bins of 32, 20, 5 and 2 gallons next to each other by the sink. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping . In addition, the facility did not provide and maintain combustibles at least 50 feet away from a 1000 gallon or greater liquid oxygen tank, 25 feet away from 1000 gallon tank or less liquid oxygen, and proper labeling of the med gas pipes. This deficiency could affect 11 of the 11 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On December 2, 2014 at 12:10pm, surveyor observed that the bulk oxygen tank in the parking lot, had combustibles like leaves, trees and shrubs located within 50 feet of the Oxygen Tank, greater than 1000 gallons. Items besides grease canisters included trees, shrubs and plastic fencing. Surveyor observed vehicles (cars) were parked within 10'-0" of the Oxygen Farm. This observed situation was not compliant with NFPA 50 (1998 edition) section 2.2.4 and NFPA 99 section 4-3.1.1.2(a) 10 b.

2. On 12/1/2014 at 2:39 pm, observation revealed on the 1st floor in the closet to the oxygen storage room, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation did not have the valves and pipes labeled. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.4 and NFPA 99 (1999 ed.), Chapter 4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on interview and observation, the facility did not maintain the emergency electrical generator in accordance with NFPA 110 and the facility did not maintain an enunciator panel at the maintenance location. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 12/02/14 at 12:05 pm, observation outside of the building showed that the emergency generator was not provided with a battery warmer for when the temperature of the battery is below 50 F. This observed situation was not compliant with NFPA 110 (1999 ed.) section 3-3.1.

2. On 12/1/2014 at 1:49 pm, observation revealed on the 2nd floor in the maintenance area, that an anunciator panel was not located in a maintenance location. This observed situation was not compliant with NFPA 99 (1999 ed.), 3-4.1.1.15(b).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with electrical panels with complete directories, and working clearances at electrical panels. This deficiency occurred in 2 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 12/1/2014 at 11:45 am, observation revealed on the 2nd floor in the large electric room, that electrical panel breaker(s) were not labeled to identify the loads they fed. All panels in the room were missing some labeling. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

2. On 12/1/2014 at 2:45 pm, observation revealed on the 1st floor, off of the kitchen storage, room 144, that access to the electrical panel was less than 3'-0" clearance. A cart was in front of the electrical 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 E (Director of Plant Operations), staff F (Corp. Manager of Plant Operations) and staff G (Corp. Director of Plant Operations).