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Based on schematic review, observation, and staff verification the facility failed to ensure it's 2 hour fire rated walls constructed of wood were entirely covered with a noncombustible or limited-combustible material. This has the potential to affect all patients at the facility. The facility census was 61.

Findings include:

Observation of the identified 2 hour fire rated wall in the Radiology area on the 2nd floor as seen from within the radiology break room completed on 12/18/18 at 11:15 AM revealed the gypsum board did not go to the concrete above and wood was visible at the top of the wall the entire length of the room. Also noted the same wood was observed from within the Radiology Technology Manager's office.

Staff AA was asked if the wood is fire retardant treated at the time of the observation and Staff AA was unable to verify if the wood was treated. StaffAA verified the gypsum board did not go to the deck and was not sealed with a fire rated material.

Based on schematic review, observation, and staff verification the facility failed to ensure doors located in the 2 hour fire rated smoke barriers had self closing devices attached, closed to latching position, and were not propped open. This has the potential to affect all patients in the facility. The facility census was 61.

Findings include:

Observation of the third floor nurse manager's office door located in the 2 hour fire rated smoke barrier wall in the 3-West corridor completed on 12/18/18 at 9:50 AM revealed the door was open and the self closing device was disconnected from the door.

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

After the self closing device was reconnected the door was noted to have been propped open with a chair. On 12/19/18 at 11:58 AM another observation of the same door was completed and the door was noted to be in open position, when tested the self closing device failed to close the door to latching position.

This finding was verified by Staff AA at the time of the testing of the door.

Observation of the double doors in the 2 hour fire rated wall in the radiology area completed on 12/18/18 at 10:58 AM revealed that one of the double doors did not latch when in closed position.

This finding was verified by Staff AA and Staff BB at the time of the observation.

Based on schematic review, observation, and staff verification the facility failed to maintain exit passageway walls fire rating. This has the potential to affect all patients in the facility. The facility census was 61.

Findings include:

Observation above the double doors to the exit passageway for Stairwell H, outside the passageway completed on 12/18/18 at 11:38 AM revealed the wall was not sealed at deck above and drywall (2 layers) covering a hole with no fire rated material sealing the seams at the wall. This finding was verified by Staff AA at the time of the observation.

Observation of the door to the old ED entrance in the exit passageway completed on 12/18/18 at 11:49 AM revealed the door had no fire rating. This finding was verified by Staff AA and Staff BB at the time of the observation.

Observation within the exit passage way for Stairwell G above the door to the security break room completed on 12/18/18 at 1:55 PM revealed the wall not sealed at the deck for 5 feet and a 4 foot section stopping 12 inches below the deck above.

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

Based on observation and staff verification the facility failed to ensure exit and directional signs are installed in accordance with NFPA 101, 2012 edition section 7.10. This has the potential to affect all patients receiving services at the facility. The facility census was 61.

Findings include:

Observation of the corridor on the first floor just off the elevators numbered 3, 4, 5, and 6 completed on 12/19/18 at 9:40 AM revealed no exit signs in any direction. Three options were noted for exit egress from this location.

These findings were verified by Staff AA and Staff BB at the time of the observation.

Based on schematic review, observation, and staff verification the facility failed to maintain the fire rating of vertical openings. This has the potential to affect all patients in the facility. The facility census was 61.

Findings include:

During schematic review and tour that was conducted on 12/18/18 between the hours of 8:30 AM and 4:00 PM the following findings were noted:

3rd floor

1. Two 3/4 inch conduits open on the end, not sealed where wall meets deck, and two 2 inch pipes at deck not sealed around annular space in the chase to the the right of the door to stair H. Also in the corridor an electrical panel was noted to have open space around the plates and can see into chase space.

2. A 1/2 inch conduit with white and blue phone cables was noted to be open on the end in the East wall of Stairwell H as seen from the corridor. A 1/2 inch conduit passing through a 8 inch by 4 inch section of missing block at the East corner of the chase by Stairwell H and a 4 inch open space was noted between two HVAC ducts, a wire mesh was noted at the top of this space in the South wall of the chase by Stairwell H.

3. Multiple 1/2 inch penetrations just above the top of gypsum board located in the North wall of the Chase located beside Stairwell G.

4. A 3 inch by 2 1/2 inch penetration with 1/2 inch copper water line penetrating the West chase wall by Stairwell G.

5. A 2 foot by 1 foot opening with 6 inch pneumatic tube passing through above the concrete drop ceiling in the East wall of the chase located in the admissions area, as seen from the corridor.

6. A 1 inch by 6 inch space at the top of wall where it meets the deck at the corner of chase wall behind elevator 5 as seen from the corridor.

7. A 4 inch space above an HVAC duct that ran entire length of HVAC duct penetrating the East wall of the Chase by Stairwell F.

8. An open spaces around electrical panels into the chase located in the soiled utility room penetrating the wall of the Chase located in 3-South.

2nd floor

9. A steel beam was noted penetrating the North wall of the chase located behind Elevators 5 and 6 it was not sealed with a fire rated material at the wall location, as seen from inside the physicians lounge beside the double doors.

During tour that was conducted on 12/19/18 between the hours of 8:30 AM and 3:00 PM the following findings were noted:

1st floor

10. Multiple penetrations varying in size and shape were noted in the South Wall of Stairwell G as seen from within the room adjacent to the stairwell.

All findings were verified by Staff AA and Staff BB at the time of the observations.

Based on observation and staff verification the facility failed to ensure the tiles in hazardous areas were smoke tight and the walls in the spaces were free of penetrations. This has the potential to affect all patients in the facility. The facility census was 61.

Findings include:

Observation of the South most soiled utility room and biohazardous room located on the 1st floor completed on 12/19/18 at 10:30 AM revealed multiple penetrations in the lower portions of the walls and multiple tiles were missing or not in place.

This finding was verified by Staff AA and Staff BB at the time of the observation.

Based on schematic review, observation, and staff verification the facility failed to maintain the fire rating of its identified 1 hour and 2 hour fire rated smoke barriers. This has the potential to affect all patients in the facility. The facility's census was 61.

Findings include:

During tour completed on 12/18/18 between the hours of 8:30 AM and 4:00 PM the following findings were noted:

3rd floor

1. A 6 inch X 6 inch penetration with copper water line passing through, two 1/2 inch copper water lines cut off and open on the end and multiple 1 1/2 inch by 1/2 inch penetrations at top of gypsum board in the South wall of the room across from Stairwell G as seen from within the room.

2. No fire rated material was noted at the top of the fire rated wall and a 3 inch by 2 inch section cut out and not sealed around just outside the door of stairwell G.

3. A 4 inch round penetration with copper water line passing through and a 2 inch round penetration just above that is penetrating the admissions office North wall, as seen from within the admissions office.

4. Two penetrations one with a 1 1/2 inch copper line and one with 3/4 inch copper line in the RN managers office West wall located in 3-West, as seen from within the office. Same penetrations were noted in the adjacent room as well.

2nd floor

5. A 2 1/2 foot section not to deck above the entire length of the empty room with beds adjacent to the Exercise Tolerance lab. This wall was identified as having a 2 hour rating and appeared to have two walls side by side and the other side was noted to have been constructed of wood and gypsum board which was not sealed at the deck above.

6. A 2 foot by 7 inch opening through both sides of wall with a 6 inch sewage line passing through, a 7 inch by 7 inch opening in the Right corner, and old yellow caulking pulling away where the wall meets the deck in the East wall of the old X-ray room.

7. A 5 inch by 8 inch opening with multiple blue and white data cables passing through the 1 hour rated wall above the double doors located in the south most cross corridor running east west between Radiology and old ED.

8. A 2 inch penetration above the double doors just outside stairwell G with orange cable passing through. Same penetration is noted on opposite side of wall as well.

9. An 8 inch section of area patched with brick was noted and not sealed around the brick seams in the South wall of the room with a washer and dryer located in the old medical records space.

10. A 4 inch by 12 inch penetration in the center of the North wall of the physicians lounge area.

11. Not sealed where wall meets deck, above the double doors to the physicians lunge area.

12. A half inch conduit open on the end above double doors to 2-West as seen from the 2-South side.

13. Wall not sealed where it meets deck, above double doors to the high observation unit as seen from the 2-South side.

During tour completed on 12/19/18 between the hours of 8:30 AM and 12:00 PM the following findings were noted:

1st floor

14. A 1 foot by 3 foot section of brick missing out of the North wall of the old clinical Resource management room just inside the door of the room.

15. A 1 inch conduit with open annular space and the wall not sealed at the concrete to the right of the double doors just outside Stairwell G on the 1-North side. Just on the other side of the same double door a 2 inch conduit with blue and white data cables open on the end was noted.

16. A 2 inch by 1 1/2 inch penetration with blue and white data cables above the double doors located just outside the clinical engineering workshop. Two additional penetrations were noted with blue an white data cables just on the other side of the same double doors.

17. The wall was not sealed at the deck above and several penetrations were noted above two 6 inch conduits in the North wall of the clinical engineering workshop as seen from the corridor.

18. A 4 inch black plastic corrugated conduit open through the wall above the double doors located outside the door labeled Beard Barton Chair Room.

19. An 8 inch pipe sleeve, with open space around water line, penetrating the East wall of the "forms room".

20. A 1 1/2 inch conduit open on the end with blue and white data cables above the double doors by the auditorium as seen from the South side of the corridor.

21. A 6 inch conduit with open annular space penetrating the East wall of the corner office of the Quality department space.

22. A 3 inch by # 3 inch penetration to the right of the HVAC duct above the double doors just outside the door labeled 1ED28.

All findings were verified by Staff AA and Staff BB at the time of the observations.

Based on documentation review and staff interview the facility failed to ensure all fire and smoke dampers were tested at least every 6 years and all dampers functioned as designed. This has the potential to affect all patients at the facility. The facility census was 61.

Findings include:

Review of the "Fire/Smoke Damper Maintenance Record" documentation dated as completed between 10/20/17 and 11/03/17 completed on 12/17/18 revealed several Smoke Dampers and Fire Dampers were not tested and/or failed testing. No documentation was noted as to the corrective actions taken to correct failed dampers or access dampers for testing. A request was made on 12/17/18 and again on 12/18/18 for documentation of all the Fire/Smoke Dampers passing testing.

Interview with Staff AA on 12/19/18 at approximately 1:30 PM revealed the company that completes the testing did not send requested documentation and will no longer respond to requests.

Based on documentation review and staff interview the facility failed to document electrical receptacle testing. This has the potential to affect all patients at the facility. The facility census was 61.

Findings include:

A request was made for electrical receptacle testing for the receptacles at patient bedsides on 12/17/18 at 9:30 AM.

Interview with Staff A on 12/17/18 revealed that they do test the receptacles annually but do not document this anywhere.

Based on observation and staff interview the facility failed to ensure the generator remote annunciator panels were located in an area manned 24 hours a day. This has the potential to affect all patients at the facility. The facility census was 61.

Findings include:

Observation of the remote annunciator panels completed on 12/19/18 at 1:45 PM revealed they were located in the old security office. The office only had 2 chairs with no desks or work stations noted. No person was in the room during the observation.

Interview with Staff BB on 12/19/18 at 1:45 PM revealed that the area is not a manned location.