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Based on observations and confirmed by staff, the facility failed to ensure corridor walls are constructed as required. Section 19.3.6.2.3 states fixed fire window assemblies in accordance with 8.2.3.2.2 shall be permitted in corridor walls.

THE FINDINGS INCLUDE:

- During the morning hours of 5/20/13 while touring the facility, it was observed that the corridor walls on the 4th floor level of the Kaplan building are not maintained as required. Resident rooms #408 & 411 were noted as having unsealed penetrations in the corridor walls below the ceiling tiles around various duct work/piping.

This was acknowledged by the Owner, Chief Operating Officer (COO), and the Director of Plant Operations during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that corridor doors are maintained as required.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 5/20/13 while touring the facility, it was observed that there are numerous doors which will not latch when in the closed position. These doors include but are not limited to the following locations:

1) All of the patient room doors on the 5th floor of the Main Building do not close & latch properly. All of these doors have recently had Personal Protective Equipment (PPE) door mounted storage systems (door caddies) installed/mounted to the corridor side of the doors. The installation process resulted in the front portion of the hanging bars to protrude approximately 1/2" from the door face. When the doors were tested for operation, the bars hit the top jamb preventing the door from fully closing & latching.
Note: The facility started to remove the door caddies during the survey date.

2) The following doors would not close & latch do to doors out of adjustment: Patient rooms K305; K303; K210; K201; and the Main 4th floor Sitting Room door.

This was acknowledged by the Owner, Chief Operating Officer (COO), and the Director of Plant Operations during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 5/20/13 while touring the facility, the following items but not limited to were observed regarding hazardous areas (electrical rooms):

1) The non-sprinklered electrical closet on the 4th floor level of the Fertel Building (across from room #403) has unsealed penetrations around various conduit.

2) The non-sprinklered main electrical vault adjacent to the cafeteria has unsealed penetrations around various conduit as well as missing concrete blocks.

This was acknowledged by the Owner, Chief Operating Officer (COO), and the Director of Plant Operations during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that stairwells are maintained as required. Section 4.5.7 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

THE FINDINGS INCLUDE:

- During the morning and afternoon hours of 5/20/13 while touring the facility, the following items were noted regarding stairwells:

1) Stairwell doors "G" & "H" located on the 2nd floor level of the Kaplan Building have been altered since the original construction. The doors originally consisted of two 30" door leaves, but have since been changed to a single 44" swinging door. The remaining portion of the door opening was filled in by welding a steel mullion onto the frame and in-filling the other 16" portion with gypsum wall board. Although the door is equipped with a 90-minute label as required for the 5-story building, the 16" portion which was in-filled does not have the appropriate fire rating.

2) Stairwell door "D" on the 4th floor level has unsealed penetrations around conduit, BX cable, and various piping on both the stair & corridor sides of the wall.

3) Stairwell door "C" on the 4th floor level has unsealed penetrations around conduit, BX cable, and various piping on both the stair & corridor sides of the wall. In addition, the door would not latch when tested for proper operation.

4) Stairwell door "E" on the 1st floor level would not latch when tested for proper operation.

5) Stairwell door "A" on the 4th floor level would not latch when tested for proper operation.

This was acknowledged by the Owner, Chief Operating Officer (COO), and the Director of Plant Operations during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that egress doors readily open. Section 7.2.1.4.5 requires doors in the path of egress to fully open with a force not to exceed 15lbf (67N) when releasing the latch, 30lbf (133N) to set the door in motion, and 15lbf (67N) to open the door to the minimum required with. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.

THE FINDINGS INCLUDE:

- During the morning hours of 5/20/13 while touring the facility, it was observed that the Stairwell "B" door which exits to the exterior does not open as required. The door is getting stuck on the threshold as it appears to have lifted from the concrete slab.The door had to be pushed against with full body weight to set the door in motion.

Based on observations and confirmed by staff, the facility failed to ensure that the fire plans outlining the fire/smoke walls prepared by an independent consultant are maintained. Section 19.7.1.1 states the administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 5/20/13 while touring the facility, the following but not limited to fire walls were noted as being deficient in some manner:

1) The 2-hour wall on the 2nd floor of the Kaplan Building as outlined in the plans provided is not intact. The wall is missing above the ceiling tiles of the oxygen storage room adjacent to the nursing station. The walls appears to have been removed in sections to make repairs and/or modifications.

2) The 2-hour wall on the 4th floor of the Fertel Building as outlined in the plans provided is not intact. The wall was observed as having the following deficiencies:
a) Conference Room: unsealed penetrations around various data lines, the wall also stops approximately 3/4" short of the decking above with an unsealed void along the entire length
b) Rehabilitation Room: unsealed penetrations around various data lines, coax wire, and various piping, the wall also stops approximately 3/4" short of the decking above with an unsealed void along the entire length.
c) The Rehabilitation Room is equipped with a 20-minute door and not a 90-minute door as required.

This was acknowledged by the Owner, Chief Operating Officer (COO), and the Director of Plant Operations during the exit interview process.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA #72 (National Fire Alarm Code) section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.
NFPA 72 section 2-3.5.1 states smoke detectors shall not located in a direct airflow nor closer than three feet (3') from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

- During the morning and afternoon hours of 5/20/13 while touring the facility, the following items were noted regarding the fire alarm system:

1) The smoke detector located on the Main roof level within the telephone room is currently wrapped in plastic. When asked, the hospital electrician did not know why the smoke detector was wrapped or who would have done it without notifying hospital staff.

2) Smoke detectors are located approximately 1' from an air diffuser in the following but not limited to locations: In the entry way of the electrical room #PL31; and in the entry way of the electrical room #PL11.

This was acknowledged by the Owner, Chief Operating Officer (COO), and the Director of Plant Operations during the exit interview process.

Based on observations and confirmed by staff, the facility failed to assure that cubicle curtains are equipped with the proper mesh opening sizes. NFPA 13 section 5-6.5.3 states continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. CMS regulations state that privacy/cubicle curtains be installed so that the top of the curtains are at least 18" below the ceiling or the top 18" of the curtains be constructed with a mesh in which the mesh is open 1/2" or greater in the diagonal.
Section 5-6.4.1.1 states under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).

THE FINDINGS INCLUDE:

- During the morning and afternoon hours of 5/20/13 while touring the facility, the following items were noted regarding the sprinkler system:

1) The following sprinklered patient rooms: #309, #308, #306, #305, #303, #302, and #301 have cubical curtains which have 1/4" mesh on the top portions of the curtains. The rooms are equipped with sidewall mounted sprinkler heads on one wall, in order for the spray pattern to reach the opposite side of the room, the water must pass through two cubicle curtains.

2) In-lay ceiling tiles are missing from the ceiling grid therefore the sprinkler heads located in Environmental Services Room #2078 are mounted at approximately 4' below the decking above.

This was acknowledged by the Owner, Chief Operating Officer (COO), and the Director of Plant Operations during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that medical gas systems and bulk oxygen tanks are in accordance with NFPA 50 and 99.
NFPA 99, Section 4.3.1.1.2(a)10b and NFPA 50, Section 4.2.2 requires weeds and long grass within 15 feet of the bulk oxygen tank to be cut back.

THE FINDINGS INCLUDE:

- During the morning hours of 5/21/13 while touring the facility, it was observed that weeds and bamboo plants are growing within the bulk oxygen enclosure.

This was acknowledged by the Owner, Chief Operating Officer (COO), and the Director of Plant Operations during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that wall mounted alcohol hand sanitizers are installed in proper locations.

THE FINDINGS INCLUDE:

- During the morning and afternoon hours of 5/20/13 while touring the facility, hand sanitizers were observed as being mounted directly above receptacles in the following but not limited to corridor locations: outside of rooms K505; K204; Main nursing station

This was acknowledged by the Owner, Chief Operating Officer (COO), and the Director of Plant Operations during the exit interview process.