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21957




Based on observation, staff verification and interview, it was determined this facility failed to ensure the building construction type met the requirements of at least a two hour fire rating regarding the floors and upper decking. This had the potential to affect all those utilizing this facility. The facility census was 85 at the beginning of the survey.

Findings include:

Tour of building # 1 took place on 08-16-11 through 08-17-11 with staff members BB and DD. During tour of the fourth floor east wing of the lab area near the pathology office and above the ceiling tile, observation was made of one layer of 5/8 inch drywall mounted to the bottom of unprotected steel girders and beams. Interview with staff DD at the time of this observation confirmed this was only one layer of 5/8 inch drywall and it was mounted on unprotected steel girders and beams.

Tour of the third floor north wing at the northwest section on the north side of the smoke barrier doors and above the ceiling tile, observation was made of unprotected steel girders.
Staff DD verified this finding at the time of this observation.

Tour of the second floor corridor of the east/west wing at the fire barrier entering the corridor to the regional referral building and above the ceiling tile, observation was made of one layer of 5/8 inch drywall mounted to unprotected steel girders.
Additionally, at the far end of the north wing and around the corner between rooms 2503 and 2504 and above the ceiling tile, observation was made of unprotected steel girders supporting an unprotected steel deck. Staff DD verified this finding at the time of this observation.

Tour of the ground floor dietary department within the kitchen area and above the ceiling tile, observation was made of unprotected steel beams and girders supporting an unprotected steel deck.
Tour of the northwest wing, X-ray room # 9, observation was made of unprotected steel girders and I-beams.
Additionally, above the corridor door leading to the Family Practice and Medical Education buildings, observation was made of unprotected steel girders and upper decking.
Staff DD verified these finding at the time of these observations.


On 08-17-11 at 9:10 AM interview was held with staff AA and an outside professional architecture identified as FF. Review was performed of the buildings floor plans and the above observations were expressed to FF. This surveyor stated the observations made reveal this building, being unprotected in several areas, down-grades it's fire resistance rating to 000. FF agreed with this finding and stated it is the facility's intention to upgrade this building in order to meet the requirements of the building construction type II(222).


Surveyor: Binder, Chris

On 08/16/11 at 2:30 P.M. a tour of the first floor surgery wing was conducted. Present during the tour was Staff AA and EE. Observation was made above the ceiling tile of an untreated steel I-beam near the elevators located by the surgical waiting area. Additionally, observation was made of an untreated steel upper deck located in the staff lounge at the end of the east corridor.

During the tour on 08/16/11 at 2:15 P.M. Staff AA verified this finding.

On 08/17/11 at 11:05 A.M. a tour of the fourth floor northwest wing was completed. Observation revealed wooden two by fours above the drop-down ceiling mounted to the building frame on each side at the west end of the corridor. The two by fours were approximately two feet in length.
Additionally, at 11:05 A.M. at the double doors near room 4506, and at 11:20 A.M. near room 4511 at the west end of the corridor, observation was made of untreated steel decking above the drop down ceiling.

During the tour on 08/17/11 at 11:05 A.M., Staff AA verified the finding.

On 08/17/11 at 11:47 A.M. a tour of the third floor northwest wing was conducted. Present during the tour was Staff AA and EE. Traveling west down the corridor, observations made above the drop-down ceiling at 1:25 P.M. revealed unprotected steel upper decking near the double doors by patient room 3806.
Additionally, at 1:31 P.M. and 1:40 PM observation was made near the nursing station and near patient room 3816 respectively, of an unprotected steel ceiling with two wood beams running the length of the corridor.
At 1:26 P.M. above the drop down ceiling next to the nursing station a non-structural wooden beam was observed to run across the corridor.
On 08/17/11 at 1:26 P.M. Staff AA verified the findings. He/she explained the wooden beams running the length of the corridor are used as a cat-walk to allow access to shut-off valves.
On 08/17/11 at 2:15 P.M. a tour of the second floor northwest wing was conducted. Present during the tour was Staff AA and EE. Observation was made of unprotected steel upper decking above the drop-down corridor ceiling at the listed times and locations: 2:45 P.M. near patient room 2507; 3:02 P.M. near patient room 2518; 3:12 P.M. near patient room 2520, and 3:22 P.M. near exam room 1.

These findings were verified by staff members AA and EE during the survey at the times listed above.

21957








Based on observation during tour and staff verification it was determined this facility failed to ensure all corridors lacking a suppression system had walls constructed with at least a one half hour fire resistance rating and extended to the upper deck. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 85.

Findings include:

Tour of building # 1 took place on 08-16-11 through 08-17-11 with staff members BB and DD. During tour of the third floor north wing corridor by the housekeeping closet, observation was made of one unsealed conduit with a blue wire passing through.

This finding was verified by staff DD during tour of this area.


Surveyor: Binder, Chris

On 08/17/11 at 8:45 A.M. a tour of the surgery wing operating room section was conducted. Present during the tour was Staff AA and EE. At 8:50 A.M. observation was made above the drop down ceiling in the north/south corridor of a four foot long by two foot wide square penetration within the corridor wall shared with OR number 1.
On 08/17/11 at 8:45 A.M., Staff AA verified the finding.

On 08/17/11 at 2:15 P.M. a tour of the second floor northwest wing was conducted. Present during the tour was Staff AA and EE. At 2:58 P.M. observation was made above the drop down ceiling on the south side of the corridor near the nurses ' station of two, quarter size penetrations within the corridor wall shared with the bathroom.
At 3:12 P.M. observation was made above the drop down ceiling on the north side of the corridor of four, quarter size penetrations within the corridor wall shared with patient room 2520.
During the tour on 08/17/11 at 2:15 P.M. Staff AA verified the findings.

Based on observation and staff verification it was determined this facility failed to ensure vertical openings were enclosed with at least a one hour fire rated construction. This had the potential to affect all those utilizing these areas of the facility. The patient census was 85 at the time of the survey.

Findings include:

Tour of building # 1 took place on 08-16-11 through 08-17-11 with staff members BB and DD. During tour observation was made of vertical openings which had doors that failed to shut properly and doors which lacked a distinguishable and legible fire resistance rating in the following locations:

Ground Floor:
*Stairwell next to the CT scanner room was observed to have a exit discharge door leading directly outside which failed to close and latch properly.

First Floor:
*West wing stairwell which is located by the legal service office was observed to have a metal door which lacked a fire resistance rating tag.
*East wing stairwell which is located near the board room was observed to have a metal door which lacked a fire resistance rating tag.

Second Floor:
*North wing stairwell located across from room # 2495 was observed to have a wood door which lacked a fire resistance rating tag.
*West wing stairwell located by the nurses' station was observed to have a metal door which lacked a fire resistance rating tag.
*Stairwell located between the west and east wings were observed to have a metal door which lacked a fire resistance rating tag.
*East wing stairwell near the storage room was observed to have a metal door which lacked a fire resistance rating tag.
*Northeast wing stairwell across from the nurses' station was observed to have a door which lacked a fire resistance rating tag.

Third Floor:
*North wing stairwell located across from room # 3349 was observed to have a wood door which lacked a fire resistance rating tag.
*West wing stairwell located by the nurses' station was observed to have a metal door which lacked a fire resistance rating tag.
*Stairwell located between the west and east wings were observed to have a metal door which lacked a fire resistance rating tag.
*East wing stairwell near the vending area was observed to have a metal door which lacked a fire resistance rating tag.
*Northeast wing stairwell adjacent to the nurses' station was observed to have a metal door which lacked a fire resistance rating tag.


These findings were verified by staff BB and Staff DD during tour of these areas. Staff DD commented that some doors were equipped with a colored peg which indicated a fire resistance rating. Staff DD was not certain of what colors equaled what fire resistance rating. This surveyor observed some of these colored wood pegs but was unable to distinguish exactly what color they were due to the age and wear of the doors.

21957



Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke/fire barriers were constructed to provide at least a one half hour fire resistance rating. This had the potential to affect all those utilizing these areas of the facility. The facility census at the beginning of the survey was 85.

Findings include:

Tour of building # 1 took place on 08-16-11 through 08-17-11 with staff members BB and DD. During tour observation was made of several penetrations located in smoke barriers and fire barriers used as a separation for smoke compartments. These penetrations were observed above the ceiling tile in the following locations:

Ground Floor:
*Within the northwest wing, X-ray room # 9, observation was made of one unsealed steel girder. Additionally, facing the smoke barrier at the southeast corner of the room and over the top of the east wall, observation was made of a large hole around pipes.
*Within the X-ray holding room observation was made of a four foot by three inch open area and a six foot by three inch open area.
*Across from the electrical room near the stairwell, observation was made of two, one foot by two inch openings with conduits passing through.
*Above the east wing smoke barrier doors, observation was made of a piece of foam insulation penetrating the drywall with wires passing through.
*Within the one hour smoke/fire barrier located in the dietary department near the doors entering the serving area, observation was made of a large open area with pipes passing through. To the right of this open area observation was made of an approximate 32 foot long by two foot wide section of drywall missing to the upper deck.
Following the smoke/fire wall around to the dietary office, observation was made in the north wall of the office an approximate four foot by two foot section of drywall missing to the upper deck.
At the front of the office observation was made of an approximate 14 foot by two foot section of drywall missing to the upper deck. Additionally, the smoke/fire barrier office area contained a non-fire rated door and two non-fire rated windows. Both windows together measured 53 inches by 32 inches.
Above the double doors entering into the dietary area from the corridor, observation was made of a large open area in the wall.
*Above the corridor door leading to the Family Practice and Medical Education buildings, observation was made of an approximate 14 foot section of unsealed drywall between the corrugation of the metal deck and the top of the drywall.

First Floor:
*Within the west wing film storage room, observation was made of an approximate four foot by one foot open area.
*At the east wing smoke barrier and within the CNO office, observation was made of one unsealed flex line.

Second Floor:
*At the northeast wing smoke barrier, observation was made of the door located in the physician's office which failed to close properly.
*At the nurses' station observation was made of an eight foot by 16 inch section of drywall missing to the upper deck.
*Within the conference room at the nurses' station, observation was made of one unsealed flex conduit, and an approximate one foot diameter hole located in the ceiling. Additionally, two holes measuring approximately eight inches and three inches in diameter were observed in the smoke wall.

Third Floor:
*At the smoke barrier which divides the east and west wings, observation was made of a junction box which did not have a cover plate and an open conduit was exposed which penetrated the smoke barrier.

Fourth Floor:
*At the fire barrier located between the north and west wings by the elevator, observation was made of one open end conduit and an approximate two inch by six foot gap between the top of the drywall and the upper deck.


These findings were acknowledged by staff members BB and DD during tour.

Surveyor: Binder, Chris
On 08/15/11 at 9:00 A.M. a tour of the first floor surgery wing was conducted. Present during the tour was Staff AA and EE. At 9:30 A.M. a penetration of an annular space surrounding blue wires in a conduit was observed in the fire wall above the double doors in the west corridor between the northwest wing and the surgery wing. One annular space penetration in a communication pipe conduit was observed in the smoke wall over the double doors on the west corridor next to a locker room. Four circular penetrations were observed in the smoke wall over the double doors west of the anesthesia conference room. At 11:15 A.M. three penetrations in a smoke wall were observed within a black pipe, a stainless steel conduit, and blue wires on the north side of the wing over the steam sterilizers.
On 08/15/11 at 11:15 A.M. Staff AA verified the findings.

On 08/17/11 at 11:47 A.M. a tour of the third floor northwest wing was conducted. Present during the tour was Staff AA and EE. On 08/17/11 at 11:47 A.M. two circular penetrations were observed in the fire wall over the fire door located near the most eastern part of the corridor, near patient room 3499.
On 08/17/11 at 11:47 A.M. Staff AA verified the finding.

On 08/17/11 at 2:15 P.M. a tour of the second floor northwest wing was conducted. Present during the tour was Staff AA and EE. At 3:20 P.M. one circular penetration was observed in the smoke wall over the double doors on the west end of the building next to the doctor's lounge.
On 08/17/11 at 3:20 P.M. Staff AA verified the finding.

On 08/16/11 at 2:15 P.M. a tour of the first floor northwest wing was conducted. Present during the tour was Staff AA and EE. An annular penetration surrounding a communication conduit in a smoke wall above the double doors next to room 1506 was observed. A circular penetration in the fire wall above the double doors on the west side of the corridor next to the computer equipment room was observed.
During the tour on 08/16/11 at 2:15 P.M. Staff AA verified the finding.

21957


Based on observation and staff verification it was determined this facility failed to ensure all hazardous areas which lacked a suppression system was constructed with at least a one hour fire resistance rating. This specifically applied to penetrations and non-rated fire doors. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 85.

Findings include:

Tour of building # 1 took place on 08-16-11 through 08-17-11 with staff members BB and DD. During tour observation was made of several penetrations in hazardous areas lacking a suppression system located in the following areas:

Second Floor:
*Within the north wing hazardous area located between the conference room and the med room, observation was made of two large open areas around the duct and an approximate ten foot by two foot section of drywall missing to the upper deck of the south wall.
*Within the west wing soiled utility room observation was made of eight penetrations around the four walls ranging from a few inches to one foot in diameter.
*The east wing soiled utility room door lacked a fire resistance rating.

Third Floor:
*Within the north wing soiled utility room observation was made of the north wall which failed to extend to the upper deck from above the ceiling tile. Additionally, the door had a fire resistance rating of 20 minutes.
*Within the west wing soiled utility room observation was made of a non-fire rated wood door. Additionally, the entire north and west walls above the ceiling tile failed to reach the upper deck as did a portion of the south wall.

These findings were verified by staff members BB and DD during tour.


Surveyor: Binder, Chris
On 08/17/11 at 11:47 A.M. a tour of the third floor northwest wing was conducted. Present during the tour was Staff AA and EE. At 11:47 A.M. the most eastern fire door was observed to lack a fire resistance rating tag.
Staff AA verified the finding on 08/17/11 at 11:47 A.M.

On 08/17/11 at 11:50 A.M. the fire door across from a bank of three elevators was observed to lack a fire resistance rating tag.
Staff AA verified the finding on 08/17/11 at 11:50 A.M.

On 08/17/11 at 2:15 P.M. a tour of level two of the northwest wing was conducted. Present during the tour was Staff AA and EE.

On 08/17/11 at 2:22 P.M. the fire doors across from the bank of three elevators was observed to lack a fire resistance rating tag.

On 08/17/11 at 3:10 P.M. the fire doors across from patient room 2520 was observed to lack a fire resistance rating tag.
On 08/17/11 at 2:22 P.M. and 3:10 P.M. Staff AA verified the findings.

Based on observation and staff verification it was determined this facility failed to ensure patient room doors were not equipped with locks as required by the National Fire Protection Association (NFPA) Chapter 19.2.2.2.2 and latching devices have an obvious method of operation under any lighting condition and doors shall be operable without more than one releasing operation according to NFPA 7.2.1.5.4. This had the potential to affect all patients utilizing this room. The patient census at the beginning of the survey was 85.

Findings include:

Tour of building # 1 took place on 08-16-11 through 08-17-11 with staff members BB and DD. During tour of the third floor sleep lab room located by the control room, observation was made of a patient room door having a thumb lock mounted above a door handle which was also equipped with an operational latch. This required a two-step procedure to exit this room when the thumb lock was utilized.

This finding was acknowledged by both staff members BB and DD during tour of this area.

Based on observation and staff verification it was determined this facility failed to ensure all paths of egress contained properly located directional signs in accordance with the National Fire Protection Association (NFPA) 7.10. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 85.

Findings include:

Tour of building # 1 took place on 08-16-11 through 08-17-11 with staff members BB and DD. Within the first floor main lobby discharge area located between the west and east wings, observation was made of a directional exit sign mounted in front of the male and female restrooms. This sign had a arrow pointing the way of egress to the south. Coming from the west wing heading to the main lobby area, it appeared this exit sign was pointing the path of egress to an area beyond the main exit discharge doors which happened to be an alcove leading to the restrooms.

These findings were verified by staff members BB and DD during tour of this area.

Based on observation and staff verification it was determined this facility failed to ensure all components of the fire alarm system was installed according to the National Fire Protection Association (NFPA) 72, specifically in regards to the location of the manual pull station device. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 85.

Findings include:

Tour of building # 1 took place on 08-16-11 through 08-17-11 with staff members BB and DD. Within the first floor main lobby discharge area located between the west and east wings, observation was made of no manual fire pull device located near or around the exit discharge doors. The nearest manual fire pull devices was located approximately half way down each of the west and east corridors.

These findings were verified by staff members BB and DD during tour of this area.

Based on observation during tour and staff verification, it was determined this facility failed to ensure all sprinkler heads were continuously maintained in regards to cleaning the dust and debris from the sprinkler pendants and they were fitted with escutcheon rings ensuring they were in a reliable operating condition at all times. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 85.

Findings include:

Tour of building # 1 took place on 08-16-11 through 08-17-11 with staff members BB and DD. During tour observation was made of several sprinkler heads which were covered with dust and/or debris and some lacked escutcheon rings located in the following locations:

Ground Floor:
*Within the medical annex lab area, observation was made of at least four dirty sprinkler heads.

Second Floor:
*Dirty sprinkler heads located within the northeast wing nurses' station, conference room and near room # 2116.

Fourth Floor:
*Dirty sprinkler heads located in the northeast wing in the room across from the electron microscope room.
*Missing escutcheon rings from three sprinkler heads located between the east and west wings by the elevators and within the toxicology room.
*Dirty sprinkler heads within the processing room of the north wing.
*Dirty sprinkler heads within the chemistry and hematology areas of the north wing.

These findings were verified by staff BB and Staff DD during tour of these areas. This surveyor questioned staff BB regarding the routine maintenance of the sprinkler heads and staff BB stated they do not currently have a regular maintenance program for keeping the sprinkler heads free of dust and debris.

21957


Based on observation and staff verification, it was determined this facility failed to ensure the laundry chute discharge remained clear of any obstructions to enable the chute door to close properly in the event of an emergency. This had the potential to affect all areas utilizing this laundry chute system. The patient census was 85 at the beginning of the survey.

Findings include:

Tour of building # 1 took place on 08-16-11 through 08-17-11 with staff members BB and DD. During tour of the ground floor laundry chute discharge room observation was made of several bags of laundry which were located in a large mobile container located directly under the discharge chute. The mobile container was completely filled and the laundry bags continued to pile up, backing up into the laundry chute which prevented the normal operation of the chute door.

Staff member BB contacted the department manager and he/she stated the laundry is removed three or four times daily but they do not keep record of what times this job is performed throughout each day.


Surveyor: Binder, Chris

On 08/16/11 at 3:30 P.M. the chute room on the surgery wing (first floor), was surveyed. Two chutes were observed: one for linen, one for trash. Neither chute door self-closed completely when they were disengaged from the fusible link. The chute room was sprinklered.
On 08/16/11 at 3:30 P.M. Staff AA verified the findings.

On 08/18/11 at 1:10 P.M. the trash chute room on the ground level of the ED Wing was surveyed with Staff AA. The surveyor observed the trash chute room to have trash bags in the trash receptacle backing up into the chute itself such that the chute door could not close.

On 08/18/11 at 1:10 P.M. Staff AA verified the finding, saying the staff monitoring that room was probably at lunch.

On 08/18/11 at 1:17 P.M. the linen chute room on ground level of the ED Wing was surveyed with Staff AA. The door to the chute was observed to not completely close upon removal of the fusible link, leaving approximately 25 percent of the chute still open.

On 08/18/11 at 1:17 P.M. Staff AA confirmed the finding, saying he/she thought a spring was broken.

Based on observation during tour and staff verification it was determined this facility failed to ensure all mobile trash collection receptacles with a capacity greater than 32 gallons were located in a room protected as a hazardous area when not attended. This had the potential to affect all those utilizing this area of the facility. The facility census was 85 at the beginning of the survey.

Findings include:

Building tour took place on 08-17-11 with staff members BB and DD. During tour of the physical and occupational therapy area, particularly the northeast stairwell, observation was made of a large mobile trash container unattended beside the stairwell.

This was verified by staff members BBB and DDD during tour on 08-17-11.

Based on observation and staff verification, it was determined this facility failed to ensure the medical gas storage area was protected as required in regards to a ventilation system and location of light switches and receptacles. This had the potential to affect all those utilizing this area of the facility. The patient census was 85 at the beginning of the survey.

Findings include:

Building # 1 tour took place on 08-16-11 through 08-17-11 with staff members BB and DD. During tour of the ground floor medical gas storage room, observation was made of a combination light switch/receptacle located within the room and by the door leading directly outside, mounted less than five feet from the floor. Additionally, this room laced a ventilation system.

These findings were verified by staff members BB and DD during tour of this area.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patients, staff and visitors utilizing this area of the facility. The facility census was 85 at the beginning of the survey.

Findings include:


Tour of building # 1 took place on 08-16-11 through 08-17-11 with staff members BB and DD. During tour observation was made of several smoke detectors located near air flow devices in the following locations:

Ground Floor:
*Within the cath lab control room, one smoke detector
*Cath lab corridor by lab # 4, two smoke detectors
*Cath lab corridor by lab # 1, one smoke detector
*Within the holding room area
*Within the control room between the CT scanner rooms, one smoke detector
*Within the X-ray holding room
*Within the film processing room

Second Floor:
*Within the northeast wing far north storage area, one smoke detector
*Within the nourishment room, one smoke detector
*Within the waiting room by the stairwell, one smoke detector

Third Floor:
*Within the east wing corridor by room #'s 3222 and 3234, two smoke detectors
*Within the corridor by the smoke doors separating the east wing from the north wing, one smoke detector
*Within the nursery, one smoke detector

Fourth Floor:
*Within the east wing corridor by the autopsy room, one smoke detector
*In front of the double elevators between the east and west wing, one smoke detector
*Within the west wing trash room, one smoke detector

Fifth Floor:
*At the far north end of the lab near the door, one smoke detector


These finding were confirmed by staff BB and staff DD during tour.