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Based on observation and staff tour, the facility failed to maintain its interior corridors to resist the passage of smoke.

Finding are:

While on facility tour between 1:00 p.m. and 3:00 p.m. on 03-09-10 through 03-11-10, observation revealed small holes completely through several fire rated doors throughout the hospital. The holes break the fire and separation barrier and allow the spread of smoke and fire into and out of that fire containment zone.

Based on observation and staff tour, the facility failed to maintain its hazardous areas.

Finding are:

While on facility tour between 1:00 p.m. and 3:00 p.m. on 03-09-10 through 03-11-10, observation revealed a door closure removed on door 4456 in the ICU. The door closure removed broke the fire separation barrier and allowed the spread of smoke and fire into and out of that fire containment zone.

While on facility tour between 1:00 p.m. and 3:00 p.m. on 03-09-10 through 03-11-10, observation revealed that the clean linen door on 4th floor in the ICU was not self closing. The non-self-closing door broke the fire separation barrier and allowed the spread of smoke and fire into and out of that fire containment zone.

While on facility tour between 1:00 p.m. and 3:00 p.m. on 03-09-10 through 03-11-10, observation revealed room 3300 has been converted into a storage room and that the room door was not self closing. The non-self-closing door broke the fire separation barrier and allowed the spread of smoke and fire into and out of that fire containment zone.

While on facility tour between 1:00 p.m. and 3:00 p.m. on 03-09-10 through 03-11-10, observation revealed that several patient rooms throughout hospital had been converted into storage rooms and that the interior corridor doors were not provided with self closures.

Based on observation and staff tour, the facility failed to maintain its flammable and combustible liquids in the laboratory in accordance with NFPA 30.

Finding are:

While on facility tour between 1:00 p.m. and 3:00 p.m. on 03-09-10 through 03-11-10, observation revealed that flammable and combustible liquids were not being handled and stored in accordance with NFPA 30.

Based on observation and staff tour, the facility failed to maintain its automatic detection system in accordance with NFPA 72.



Finding are:

While on facility tour between 1:00 p.m. and 3:00 p.m. on 03-09-10 through 03-11-10, observation revealed that smoke detectors in several areas throughout the hospital were not 3 feet away from HVAC grills. The smoke detectors not being at least 3 feet away from HVAC grills allowed the smoke around the smoke detector to be diluted therefore would not activate the fire alarm system.

Based on observation and records review, the facility failed to maintain its automatic sprinkler system in accordance with NFPA 13.

Finding are:

While on facility tour between 1:00 p.m. and 3:00 p.m. on 03-09-10 through 03-11-10, observation and record review revealed 25 sprinkler violations throughout hospital. Failure to maintain the automatic sprinkler system to its fullness operational condition could result in the failure of the automatic sprinkler system.

Based on observation and staff tour, the facility failed to maintain its kitchen hood in accordance with NFPA 96.

Finding are:

While on facility tour between 1:00 p.m. and 3:00 p.m. on 03-09-10 through 03-11-10, observation revealed that the kitchen hood system seams were not externally welded and no drip tray was provided to collect the grease coming off of the filters.

Based on observation and record review, the facility failed to maintain its automatic generator in accordance with NFPA 99.

Finding are:

While on facility tour between 1:00 p.m. and 3:00 p.m. on 03-09-10 through 03-11-10, observation and record review revealed that the emergency generator 2 took 12 seconds to restore power to full operational condition to the hospital.

Based on observation and staff tour, the facility failed to maintain it's medical gas alarm panel in accordance with NFPA 99.

Finding are:

While on facility tour between 1:00 p.m. and 3:00 p.m. on 03-09-10 through 03-11-10, observation revealed that the medical gas alarm panel in the ICU was not visual when the test button was tested.

Based on observation and staff tour, the facility failed to maintain its electrical system in accordance with NFPA 70.

Findings are:

While on facility tour between 1:00 p.m. and 3:00 p.m. on 03-09-10 through 03-11-10, observation revealed that the electrical receptacle within 6 feet of a sink was not GFIC.

While on facility tour between 1:00 p.m. and 3:00 p.m. on 03-09-10 through 03-11-10, observation revealed that the newly installed low voltage wiring was not and is not being installed in accordance with NFPA 70, article 800 and article 300.