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Based on facility observation and staff interview and verification, the facility failed to ensure that a common wall with a nonconforming building was a fire barrier having at least a two-hour fire resistance rating constructed of materials as required. The facility had a capacity of 398 beds with a census of 108 patients.

Findings included:

On 06/07/13 between 8:50 A.M. and 2:00 P.M. tour of the facility was conducted with Staff AA and BB. Observation was completed of a two hour fire rated wall which separated the emergency department and the connecting building.

The emergency department was observed to have minimal sprinkler protection and was located in a building with a construction type determined to be Type II(222). The adjacent building was provided with complete automatic sprinkler protection and was determined to be construction type II(000). In addition to recent sprinkler protection, the facility had completed a fire safety equivalency survey (FSES) of the building with type II(000) construction.

Observation of the two hour fire rated barrier which separated the two buildings revealed the following:

* Located in the director of protective services office, observation above the ceiling tiles revealed three penetrations. One penetration was approximately three inches square. Observation on the other side of the same wall revealed penetrations surrounding two conduits and a wire which went through the wall.

* In room 839, identified by a key number, observation above the ceiling tiles revealed five penetrations, ranging from one inch in diameter to approximately 12 inches.

* Observation of the two hour fire rated wall , above the ceiling tiles from the corridor revealed the wall was stenciled as a smoke barrier. Directly above the stenciled words was a penetration approximately five inches square.

* Further observation of the two hour fire rated wall in the same area revealed three penetrations surrounding flex conduit which went through the wall.

*Located in the emergency department waiting area, observation above the ceiling tiles revealed an open sleeve that went through the wall.

*Observation of a mechanical area, located at the end of the emergency department revealed a 20 minute fire rated door. This door was located within the two hour fire rated wall.

* Located within the public bathroom in the emergency department, observation above the ceiling tiles of the two hour fire rated wall revealed a penetration approximately two inches square as well as two smaller open areas approximately one inch in diameter.

*Observation above the ceiling tiles of the two hour fire rated barrier from the ground level service corridor revealed two penetrations surrounding two pipes.

*Observation of a door leading to the tunnel, revealed the door had no noted fire resistance rating, did not positively latch and had a small hole in the door. The door was located within the two hour fire rated wall.

*Observation of two doors located within the two hour fire rated wall revealed one door, located at the northwest stair 6, had a fire resistance rating designated by a green dot. The second door, identified as the central transport door, had a fire resistance rating designated by a black dot. Staff A provided information labeled as " Weyerhaeuser Legacy Dowel Codes" to identify the fire rating of the doors. Review of the code information revealed the green dowel provided 45 to 90 minutes rating. There was no code for a dowel that appeared to be black. Staff A verified the fire rating of the doors could not be determined to meet the requirement for the location within the two hour fire rated wall.

* Observation of a door, leading to the nurses locker room, located within the two hour fire rated wall, revealed no fire rating on the door.

* Observation above ceiling tiles in x-ray room 2 of the two hour fire rated wall revealed penetrations surrounding pipe.

* Observation of the two hour fire rated wall above the ceiling tiles in the nuclear medicine room #1 revealed a penetration surrounding a two and a half inch pipe.

* Located in the ultrasound room #1 observation of the two hour fire rated barrier above the ceiling tiles revealed a penetration that appeared as if a brick had been removed from the wall.

* Located within the men's dressing room, observation above the ceiling tiles, revealed penetrations surrounding two steam pipes.

* Observation of the two hour fire rated barrier, at the employee entrance revealed a penetration in the fire rated barrier above the fire rated doors. The doors in the two hour barrier wall had a fire resistance rating of 45 minutes. In addition, the doors did not positively latch.

Staff present on tour observed and verified the observations.