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Based upon observation and interview, it was determined that facility failed to ensure the two (2) hour common wall and/or doors as directed by regulations on one of four floors.

Findings include:

Observation on June 11, 2013, between 10:45 am and 11:00 am revealed the facility had common wall door deficiencies at the following locations:
1. First floor common wall doors with the "40" Building had holes in the door.
2. First floor common wall doors to Respiratory lack a self-closing device.

Interview with Director of Facilities (DOF) on June 11, 2013, at 11:00 am confirmed the above listed common wall door deficiencies.

Based on observation and interview, it was determined the doors protecting corridor openings, in other than hazardous areas, are not substantial, or smoke resistant, as per regulations on one of four floors.

Findings include:

Observation on June 11, 2013, between 11:15 am and 11:30 am revealed the facility had corridor doors that lacked positive latching at the following locations:
1. Ground floor Kitchen door had a step stool preventing door from closing and latching.
2. Ground floor Stock Room office door lacked positive latching.

Interview with DOF on June 11, 2013, at 11:30 am confirmed the above listed doors lacked positive latching.

Based on observation and interview, it was determined the facility failed to maintain vertical openings between floors to be enclosed with construction having a fire resistive rating of one (1) hour on one of three floors.

Findings include:

Observation on June 11, 2013, between 11:00 am and 11:15 am revealed the facility has the following shafts that are not properly sealed to maintain a two-hour fire resistance rating:
A. First floor stair tower to tunnel to Pine Crest near elevator #11 has a hole in the stair block wall (11:00 am).
B. First floor staff elevator #12 has a hole in the shaft block wall (11:15 am).

Interview with MS on June 11, 2013, at 11:15 am confirmed the above vertical openings are not adequately sealed.

Based upon observation and interview, the facility failed to maintain exit and direction signs in accordance with regulations on one of four floors.

Findings include:

Observation on June 11, 2013, at 11:35 am revealed the facility lacks an exit sign indicating direction of exit travel in the ground floor outside exit foyer by the stock room.

Interview with DOF on June 11, 2013, at 11:35 am confirmed the lack of an exit sign in the outside exit foyer.

K-062

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on three of three floors.

Findings include:

Observation on June 11, 2013, between 9:17 am and 12:55 pm revealed the facility has fire sprinkler issues at the following locations:
A. Second floor data closet has two ceiling tile removed. This may delay activation of the fire sprinkler head (9:17 am).
B. First floor corridor at back door of elevator #7 has a large load of wires on top of fire sprinkler pipe (10:25 am).
C. First floor O.R. soiled utility room sprinkler shows signs of fitting leak, rust (10:30 am).
D. Ground floor corridor at top of ramp near '58 component connection link has a large load of wires on top of the fire sprinkler pipe (12:55 pm).

Interview with MS on June 11, 2013, at 12:55 pm confirmed the above listed fire sprinkler issues, and the subsequent correction of item A only during the time of the survey.

Based on documentation and interview, the facility failed to ensure that the portable fire extinguishers were installed, inspected and maintained in accordance with regulations on one of four floors.

Findings include:

Observation on June 11, 2013, at 11:10 am revealed the fire extinguisher in the Pharmacy is not visible nor is it near the exit from the Pharmacy.

Interview with DOF on June 11, 2013, at 11:10 am confirmed the fire extinguisher was not visible.

Based upon observation and interview, it was determined that the facility failed to store medical gas in accordance with regulations in one of one main medical gas storage location.

Findings include:

Observation on June 11, 2013, at 12:10 pm revealed the following issues within the ground floor medical gas tank storage room:
A. Five unsecured medical gas cylinders.
B. Four unsealed holes in the one (1) hour fire rated ceiling assembly.

Interview with MS on June 11, 2013, at 12:10 pm confirmed the above medical gas storage issues, and the subsequent correction of item A only during the time of the survey.

Based upon observation and interview, the piped-in medical gas system failed to comply with regulations on one of three floors.

Findings include:

Observation on June 11, 2013, at 10:35 am revealed first floor T.C.U. has monitors and carts blocking access to the medical gas shut offs and alarms.

Interview with MS on June 11, 2013, at 10:35 am confirmed the shut offs and alarms are blocked, and the subsequent correction of this item during the time of the survey.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of four floors.

Findings include:

Observation on June 11, 2013, between 11:05 am and 11:27 am revealed the facility had unauthorized electrical appliances plugged into surge protectors at the following locations:
1. Ground floor Pharmacy Break Room - coffee pot and microwave oven plugged into a surge protector.
2. Ground floor Stock Room office - coffee pot, toaster, and refrigerator plugged into a surge protector.
3. Ground floor Stock Room office by file cabinets - refrigerator plugged into a surge protector.

Interview with DOF on June 11, 2013, at 11:27 am confirmed the above listed electrical appliances were plugged into surge protectors and the subsequent correction of Items #2 and #3 during the time of the survey.