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Based on observation, the facility failed to provide an astragal on a 1.5 hour rated fire door which separates a nonconforming building from a health care facility, failed to fill penetrations in wall between nonconforming buildings, failed to complete walls where nonconforming buildings attach to a health care facility, and failed to properly label all fire doors between health care facilities and nonconforming buildings.

Findings include:

1. The set of fire doors which separate the Womens Health Center in the hospital building from the Broadway Building were reviewed at 9:35 a.m. on March 1, 2010. The 1.5 hour rated fire doors did not have an astragal affixed to either door. There was a space between the doors of approximately one quarter inch when the doors were in the closed position. Fire doors can not have a space greater than one eighth inch when in the closed position.

2. The two hour barrier wall on second floor of the hospital was observed at 2:45 p.m. on March 2, 2010. The wall above the set of double doors at the two hour wall had one inch penetration of the wallboard which was not sealed.



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3. The set of corridor doors adjacent to the Student study room (across the hall from the Laboratory) on the first floor was shown as being part of a two-hour fire barrier on the floor plans of the building. One of the two doors did not have a label attesting to it being at least a one and one-half hour rated door for use in openings in fire barriers as observed at 2:31 p.m. on March 1, 2010. Note: The other door did have a one and one-half hour label on it.



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4. The second floor two hour barrier between the hospital and the Broadway building was reviewed on March 3, 2010 between 8:02 a.m. and 8:11 a.m. The following deficiencies were found:

a) a disconnected, open ended electrical conduit was found that penetrated the barrier,

b) the right hand side of the wall was incomplete from the wall to the ceiling pan above door 0169 from the Broadway building going into the hospital, and

c) the right hand side of the wall was incomplete from the wall to the ceiling pan above door 0169 from the Hospital into the Broadway building.

Based on observation on March 1, 2010; the facility failed to maintain proper clearances for a set of two hour doors and failed to maintain a two hour barrier between the hospital and a nonconforming occupancy (ambulatory surgical center).

According to NFPA 80, 1999 Edition, 2-3.1.7 the clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. ± 1/16 in. (3.18 mm ± 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.

Findings include:

1. The set of two hour fire doors entering into the waiting area of the ambulatory surgery center left a gap of greater than 1/8 inch when closed. Fire doors cannot have space greater than one eighth inch when in the closed position.


2. The second floor two hour fire barrier east of the elevator lobby and stair well was observed on March 1, 2010 at 1:43 p.m. The fire barrier contained at least two electrical conduits that passed through into the ambulatory surgical center. A open space between the corridor wall and the concrete wall above contained an open area where the electrical conduit passed.

Based on observations made on March 1-2, 2010, the facility failed to maintain the fire and smoke resistance rating of ceiling and wall assemblies.

The findings include:

1. The ceiling tile in Day Surgery on the second floor of the hospital was observed at 11:30 a.m. on March 1, 2010. There were approximately eight penetrations in the ceiling tile where the old telemetry system had been removed, these were approximately 3/4 inch in diameter each.

2. The utility room in the Emergency Room was observed at 1:05 p.m. on March 1, 2010. There were approximately fifteen 1/2 inch penetrations in the back wall where some shelving had been removed.

3. The janitors closet at Day Surgery was observed at 3:10 p.m. on March 2, 2010. The ceiling tile was missing in this room, exposing an unprotected area to the ceiling cap above.



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4. The housekeeping department storage room located at the southeast corner of the first floor of the building was examined at 1:50 p.m. on March 1, 2010. Removal of one or more panels in a lay-in ceiling have the potential to hinder the ability of the sprinkler installed in that type of ceiling assembly to activate by allowing heat and smoke to enter into interstitial spaces and collect there, delaying the activation of the sprinkler to control the fire and the fire alarm system to activate. One large ceiling tile being two feet by four feet and two other smaller size tiles were observed to be out of place in the ceiling assembly of this room.

5. The enclosure housing the sterilizer units on the first floor of the building was examined at 2:21 p.m. on March 1, 2010. Removal of any section of a monolithic ceiling has the potential to hinder the ability of the sprinkler installed in that type of ceiling assembly to activate by allowing heat and smoke to enter into interstitial spaces and collect there, delaying the activation of the sprinkler to control the fire and the fire alarm system to activate. A section of the monolithic ceiling assembly measuring approximately 20 inches by 20 inches had been removed and was open to the interstitial space above.

6. An elevator mechanical room was accessed from the Central Processing suite on the first floor of the building and examined at 3:12 p.m. on March 1, 2010. The elevator mechanical room was located on a level lower than that of the Central Processing suite and accessed by means of stairs. An open penetration in the wall of this room for the hydraulic piping serving the elevator was observed and needs to be sealed with fire rated material.

7. The telephone service room on the first floor of the building located between the two banks of elevators was examined at 3:55 p.m. on March 1, 2010. Two ceiling tiles were observed to be out of place in the ceiling assembly.

Based on observations made on March 1-3, 2010, the facility failed to maintain the fire and smoke resistance rating of ceiling and wall assemblies.

Holes or missing tile in the ceiling assembly have the potential to hinder the ability of the sprinkler system installed to activate by allowing heat and smoke to enter interstitial spaces and collect there, delaying the activation of the sprinkler to control the fire and the fire alarm system to activate.

Findings Include:

1. Room 107 P3 on the first floor was reviewed on March 1, 2010 at 12:15 p.m. A camera cable entered the ceiling tile that was not sealed to the rated ceiling assembly.

2. Room 105 on the first floor was reviewed on March 1, 2010 at 12:21 p.m. One piece of ceiling tile had a quarter inch gap along the tile length between the ceiling tile and the suspended ceiling grid.

3. The men's bathroom on first floor was reviewed on March 1, 2010 at 12:25 p.m. Ceiling tile in the bathroom were damaged or had holes in them.

4. The women's bathroom on first floor was reviewed on March 1, 2010 at 12:25 p.m. Ceiling tile in the bathroom were damaged or had holes in them.

5. The first floor elevator mechanical room was observed on March 1, 2010 at 12:43 p.m. There were a total of 24 penetrations through the ceiling assembly that need to be sealed to the passage of smoke.

6. The first floor kitchen was reviewed at 12:53 p.m. on March 1, 2010. An abandoned electrical box was found with no cover near a desk. The box should be covered to resist the passage of smoke to other smoke compartments.

7. The second floor telecommunication room was reviewed on March 1, 2010 at 2:02 p.m. Holes in the ceiling tile were observed as follows:

a) a ceiling tile was in place that had a speaker removed leaving an approximately 12 inch by 12 inch hole, and

b) pipes and electrical wiring entered the ceiling assembly and were not sealed to resist the passage of smoke.

8. The second floor Adolescent Out Patient store room contained ceiling tile that had been water damaged in the lay in ceiling while some had been removed as noted on March 2, 2010.

9. The second floor telecommunication room was reviewed on March 2, 2010 at 10:50 a.m. There were penetrations of the ceiling assembly as follows:

a) at least 24 conduits with blue, brown, and white wires going to various rooms on the floor which were not sealed to prevent the passage of smoke from one smoke compartment to the other, and

b) the ceiling assembly was not complete to the conduits.

10. Room 368, the third floor elevator communicating room, was observed on March 1, 2010. The ceiling tile was incomplete or unsealed items penetrated the ceiling tile in various locations as follows:

a) unsealed conduits entered the rated ceiling assemble, and

b) where a sprinkler head missing a escutcheon ring entered the ceiling assembly damage was done to the ceiling tile.

11. In the third floor storage room where the shredder bin is housed, an escutcheon ring was found with a hole larger than required around the ceiling tile. The tile was not laying with in the ceiling assembly completely as observed on March 1, 2010 at 4:42 pm.


12. In the fourth floor "Gym", the copper pipes supplying the reheat coil were observed on March 2, 2010. The copper pipes, as they entered the ceiling tile, were not sealed.

Based on observation, the facility failed to provide documentation that all interior wall finishes comply with Section 10.2.3 of NFPA 101 Chapter 39 Existing Business Occupancies in all exit ways and corridors.

NFPA 101 39.3.3.1 Interior finish shall be in accordance with Section 10.2.

NFPA 101
10.2.3.2* Products required to be tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale.

Findings include:

There is a large amount of wood (cedar) used on the wall finishes in the exit ways of the building. Maintenance staff were not certain that the walls had been sprayed with a material to meet Class A or Class B finish requirements.

Based on observations and interviews with nursing and maintenance staff made on March 1-3, 2010, the facility failed to assure that there were no impediments to closing and latching corridor doors.

In accordance with section 19.6.6.3.3 of NFPA 101, 2000 edition; doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close.

The findings include:

1. A bladder scanner was observed to be blocking the door from closing the corridor door to Medical Intensive Care Unit (MICU) on the third floor of the hospital as observed at 2:20 p.m. on March 1, 2010.



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2. There are two doors opening onto the west exit corridor from the Pharmacy on the first floor of the building. One of the two corridor doors was no longer in use as observed at 2:38 p.m. on March 1, 2010. A shelf with supplies had been placed against this opening into the corridor system.

3. A cart storage room located off of what was described as the "dirty side" of central processing had a door opening onto the west exit corridor. Wheeled red carts were placed against this opening into the corridor system.

Based on observations on March 1 - 3, 2010; the facility had a corridor door that would not resist the passage of smoke and did not provide a dutch door with an astragal.

According to Section 19.3.6.3.6 of NFPA 101, Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows.

Findings include:

1. The second floor of "Outpatient" was received on March 2, 2010 at 10:25 a.m. The door to the social workers office had at least three unsealed, one quarter inch holes where previous door hardware had been located.

2. The third floor medication dispensing station, dutch door was reviewed during the fire drill on March 3, 2010 at approximately 11:00 a.m. The door did not contain an astragal as required.

Based on observation, the facility failed to protect all vertical openings between floors as required by Sections 39.3.1.1, and 39.3.1.2 of NFPA 101 Chapter 39 Existing Business Occupancies.

NFPA 101 Section 39.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

NFPA 101 Section 8.2.5.4 The fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four stories or more in new construction - 2-hour fire barriers
(2) Other enclosures in new construction - 1-hour fire barriers
(3) Existing enclosures in existing buildings - 1/2-hour fire barriers

NFPA 101 Section 39.3.1.2 Floors below the street floor used for storage or other than business occupancy shall have no unprotected openings to business occupancy floors.


Findings include:

1. The north east mechanical penthouse was observed at 1:30 p.m. on March 3, 2010.

a) There were three openings in the north wall to the level below around electrical wiring.

b) There were five openings in the west wall of the mechanical room into the stairway for electrical wiring and open conduits.

c) There were three holes in the wall where the Fire Alarm Control Panel (FACP) was located, these were open to the level below.

d) There were two holes in the adjoining wall for the atrium around pipes/conduits.

e) There were seven openings in the wall between the stairway and the north east penthouse for communication wire.

2. The north west mechanical penthouse was observed at 1:40 p.m. on March 3, 2010.

a) There is a hole in the adjoining wall to the medical center which was open.

3. The southwest mechanical penthouse was observed at 1:50 p.m. on March 3, 2010.

a) There were five conduit openings in the floor of the penthouse which were open to the level below.

b) There were three vertical openings for communication wiring which were open to the level below.

c) There were three open penetrations in the north wall of the penthouse which were open to the atrium of the medical center.

4. The partial basement of the medical center was observed for vertical opening at 2:00 p.m. on March 3, 2010. There is a penetration around a vent in the stairway leading to the basement.

Based on observations made on March 1, 2010, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 edition, pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

The Information Technology (IT) room on second floor of the hospital was observed at 11:20 a.m. on March 1, 2010. There was one penetration from this room to the level below (first floor cafeteria).

Based on observations which were made during a tour of the building on March 1-3, 2010, it was determined that the facility did not ensure that all doors requiring self closing hardware were closed or could close to positive latching.

Findings include:

1. The fire door (labeled 0510) on fifth north of the hospital did not latch when exercised at 7:50 a.m. on March 2, 2010.

2. The fire door to the dumb waiter access on sixth floor of the hospital did not latch as the spring had been removed and it would not self-close as required at 8:50 a.m. on March 2, 2010.



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3. A supply/storage room within the first floor maintenance suite was shown as being enclosed by one-hour construction on the floor plans of the building. The fire rated door into this supply/storage room had a chock holding it open as observed at 10:10 a.m. on March 1, 2010. There was no one occupying or using the supply/storage room at the time of the observation and the chock inhibited the self-closure mechanism on the fire door from closing and latching the door.

4. The maintenance suite area on the first floor was separated from an exit stairway to the second floor by a set of fire doors in the immediate area of the power lift assembly. A movable/wheeled bed was placed in the doorway of these fire doors as observed at 10:24 a.m. on March 1, 2010. The placement of the bed would inhibit the doors from closing and latching upon their release from the magnetic hold devices in case of an emergency. Note: The bed was removed from the doorway after the observation was made and confirmed by the surveyor while on-site.

5. The northeast exit stairway accessed from the second floor of the boiler room suite was examined at 1:10 p.m. on March 2.2010. The one and one-half hour rated door was being held open by a chock which inhibited the door from self-closing and latching.

Based on observations on March 1 - 3, 2010; it was determined that the facility did not ensure that all doors requiring self closing hardware were closed or could close to positive latching.

Findings include:

The second floor two hour barrier corridor was reviewed on March 1, 2010 at approximately 1:00 p.m. The set of fire doors labeled as 0745 were in need of adjustment based on three attempts to allow the door to close to positive latching. The door would not latch during each of the three attempts.

Based on observations, the facility failed to maintain the fire and smoke resistive rating of smoke/fire barriers.

Findings include:

1. The electrical room in the Emergency Room (ER) was observed at 12:55 a.m. on March 1, 2010. There were three penetrations along an I beam along the corridor wall which were not sealed.

2. The two hour wall between the ambulance garage and the paramedics charting room was observed at 11:45 a.m. on March 2, 2010. Two unsealed sleeve penetrations were found through the south wall for communication wiring.

3. The soiled utility room in the E.R. was observed at 11:50 a.m. on March 2, 2010. Two penetrations were found in the east wall, one in the south wall, and one in the west wall. All penetrations were for communication wiring.

4. The locker room in the E.R. was observed at 1:00 p.m. on March 2, 2010. Two penetrations were found in the north wall, one was an open three inch sprinkler pipe, and the other was a three quarter inch conduit that was open.

5. The E.R. exit foyer was observed at 1:10 p.m. on March 2, 2010. Seven penetrations were found in the east wall above the exit door at the two hour wall.

6. The east corridor wall outside of E.R. was examined at 1:12 p.m. on March 2, 2010. One three inch sprinkler pipe had not been sealed above the fire extinguisher cabinet.

7. The north wall at the double doors into Radiology was examined at 1:30 p.m. on March 2, 2010. One penetration was found in the wall above the double doors.

8. The wall was examined above the double doors into X-Ray at 1:32 p.m. on March 2, 2010. Two sleeves extending through the wall were not sealed at the end of the sleeves.

9. The east wall, near X-Ray, across from smoke detector LO3D42, was examined at 1:35 p.m. on March 2, 2010. There was a one and one half inch hole in the wallboard which was not sealed.

10. The smoke barrier wall at the X-Ray reading room was examined at 1:40 p.m. on March 2, 2010. A three inch conduit leading to a cable tray was not sealed at the smoke barrier wall.

11. The smoke barrier wall separating X-Ray from the corridor was examined at 1:50 p.m. on March 2, 2010. A sprinkler collar penetrated the wallboard on the east wall to X-Ray, exposing a hole in the wallboard around the collar.

12. The two hour wall at the second set of service elevators was examined at 2:00 p.m. on March 2, 2010. There were five penetrations of the fire wall above the set of fire rated doors.

13. The east wall of Post-Operations was examined at 2:05 p.m. on March 2, 2010. One two inch conduit was not sealed at this location along with a phone box cover missing which had branch lines extending through the same wall.

14. The smoke barrier wall at the entrance to Surgery was examined at 2:10 p.m. on March 2, 2010. A communications cable tray was not sealed at the smoke barrier wall above the doors to Surgery.

15. The smoke barrier wall at Surgery was examined at 2:15 p.m. on March 2, 2010. A three inch sewer pipe was not sealed as it passed through the north wall at Surgery.

16. The east corridor wall just south of the double doors to Surgery was observed at 2:20 p.m. on March 2, 2010.

a) There are approximately ten penetrations at the top of the smoke barrier wall where the wallboard meets the ceiling support beam.

b) A two foot by three foot piece of wallboard panel was not screwed to the smoke barrier wall and fire taped.

17. The smoke barrier wall in the mens dressing room of the Operating Room (OR) was observed at 2:30 p.m. on March 2, 2010. One penetration for communication wiring conduit was not sealed.

18. The smoke barrier wall in the women's dressing room of the O.R. was observed at 2:35 p.m. on March 2, 2010. The east wall was incomplete to the ceiling cap and there was one penetration of a communication wire through the same wall which was not sealed.

19. The east corridor wall across from Day Surgery was observed at 2:40 p.m. on March 2, 2010. There was one penetration of a three quarter inch conduit which was not sealed above the Day Surgery double doors.

20. The store room behind the Chapel was observed at 3:30 p.m. on March 2, 2010. There were six penetrations of the north wall (all conduits) which were not sealed. The wall where it intersected the ceiling cap was incomplete as the wallboard did not close off the deck flutes.

21. Second floor of the hospital, in the mens dressing room, at the west end of the smoke barrier wall between Surgery and Radiology, was observed at 8:00 a.m. on March 3, 2010. There were two penetrations of the smoke barrier wall where chilled water return and supply pipes were not sealed.

22. The smoke barrier wall between Surgery and Radiology was observed at 8:10 a.m. on March 3, 2010. There were three penetrations of the smoke barrier wall above the ceiling tile. Two of the penetrations were for conduits not sealed and the remaining was for a communication wire not sealed where it went through the wall.

23. The smoke barrier wall which separates Radiology from Surgery was observed at 8:12 a.m. om March 3, 2010.

a) There was one penetration in cubicle #5 where wallboard did not butt up to one another exposing a two inch by six inch hole in the smoke barrier wall.

b) There was one penetration at the lower right hand corner of a large two foot by two foot duct not sealed at cubicle #4 in Radiology.

c) There was one penetration of the smoke barrier wall where a one half inch conduit was not sealed in cubicle #4.

d) There was a pneumatic fire damper hose through the smoke barrier wall above the sitting area in Radiology which was not sealed.

e) There were two penetrations of the smoke barrier wall in Radiology at cubicle #2, both penetrations were for sleeves extending through the wall which were not sealed.

f) In cubicle #1, there was one junction box without a cover which had conduit extending through the smoke barrier wall.

24. The smoke barrier wall between Surgery and Nuclear Medicine was reviewed at 8:35 a.m. on March 3, 2010. There were penetrations of the smoke barrier wall where a return air trunk line extends through the wall of Nuclear Medicine by damper #480.

25. The Specials Computer Room at Radiology was reviewed at 9:30 a.m. on March 3, 2010. There were two penetrations above the ceiling tile near smoke alarm # LO2D86, one was a support wire and the other was a pneumatic tube through the smoke barrier wall which were not sealed.

26. Fire Dampers were observed at 10:20 a.m. on March 3, 2010 on fifth floor north and again on third floor north. The following is a listing of penetrations of the smoke barrier wall which were found on third north:

a) The north wall at the door to the core had a two inch penetration where communication wiring extends through the wall.

b) The east wall at the same location had two penetrations which were not sealed. One was a sleeve which was not sealed and the remaining was a air supply duct which was not sealed at the lower left hand corner.




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27. The smoke barrier above the corridor door that leads to the Credit Union office from the corridor by the first floor conference rooms was examined at 10:32 a.m. on March 2, 2010. There was an open unsealed space around a conduit that penetrates this portion of the smoke barrier.

28. The smoke barrier above the corridor door into the Central Processing suite from the corridor by the first floor elevator lobby was examined at 10:38 a.m. on March 2, 2010. There was an open unsealed space around a 12 inch white pipe and around a drain pipe that penetrate this portion of the smoke barrier. Furthermore, a thermofiber/wool type material had been used a sealant around other penetrations. The Centers for Medicare & Medicaid Services (CMS) does not accept thermofiber/wool material as a sealant in walls that require a fire resistance rating.

29. The smoke barrier above the set of corridor doors into the area that was previously the Bio-med suite on the first floor of the building was examined at 11:00 a.m. on March 2, 2010. There was an open faced conduit being used as a pass through for a white wire that was unsealed. Furthermore, a thermofiber/wool type material had been used a sealant at the meeting edge of the smoke barrier wall and the fluted deck.

30. The smoke barrier above the set of corridor doors into the IT suite from the corridor by the kitchen area on the first floor of the building was examined at 11:08 a.m. on March 2, 2010. There was an open unsealed space around a conduit that penetrates this portion of the smoke barrier. Furthermore, the meeting edges of sheetrock used in the smoke barrier wall were not fire taped/sealed completely.

31. The smoke barrier being the south wall of the IT office suite on the first floor of the building was examined at 11:17 a.m. on March 2, 2010. There was an open faced conduit with open unsealed space around it that penetrates this portion of the smoke barrier. Furthermore, there were two other conduit with open unsealed spaces around them that penetrate this smoke barrier.

32. The smoke barrier above the entry door into the Credit Union office on the first floor of the building was examined at 11:27 a.m. on March 2, 2010. There was a small round open unsealed hole in the smoke barrier.

33. The smoke barrier above the "T" intersection of the corridors by the Credit Union office and the north conference room on the first floor of the building was examined at 11:45 a.m. on March 2, 2010. A thermofiber/wool type material had been used a sealant at the meeting edge of the smoke barrier wall and the fluted deck. Furthermore, the same thermofiber/wool material had been used as a sealant around two white pipes that penetrate this smoke barrier.

34. The smoke barrier above the biohazard waste storage room on the first floor of the building was examined at 11:48 a.m. on March 2, 2010. There was no sealant at the meeting edge of the smoke barrier wall and the fluted deck.

35. The smoke barrier being the west wall of the Central Supply room on the first floor of the building was examined at 11:58 a.m. on March 2, 2010. There were two conduit with open unsealed spaces around them that penetrate this smoke barrier.

36. The smoke barrier above the north office space in what was previously the Bio-med suite on the first floor of the building was examined at 1:33 p.m. on March 2, 2010. There was an open unsealed space around a sprinkler pipe that penetrates this smoke barrier.

37. The smoke barriers above what was once the engineering secretary's office space in the area that was previously the Bio-med suite on the first floor of the building was examined at 1:40 p.m. on March 2, 2010. Both the west and south walls of this space constitute a smoke barrier. The west smoke barrier had no sealant at the meeting edges of the wall with the fluted deck. The south smoke barrier wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.




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38. The fifth floor fire doors were reviewed on March 3, 2010 at 11:17 a.m. On the north side above these doors, a telemetry sleeve was found that had not been sealed on the end.

39. The fourth floor waiting room was reviewed on March 3, 2010 at 11:22 a.m. The smoke barrier wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.

40. The fourth floor fire doors were reviewed at 11:24 a.m. on March 3, 2010. On the south side above these doors. A steel pipe passing through the barrier was not sealed around where it entered the barrier.

41. The fourth floor fire doors was reviewed on March 3, 2010 at 11:22 a.m. The fire barrier wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.

42. The fourth floor smoke barrier was reviewed on March 3, 2010 at 11:31 a.m. at Jani's Office. The barrier wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.

43. The fourth floor barrier wall was reviewed on March 3, 2010 at 11:33 a.m. above the 4 north doors. There were two deficiencies noted:

a) the wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck, and

b) a open ended telemetry sleeve was found that passes through the barrier.

44. The third floor main pipe/utility chase barrier was reviewed on March 2, 2010 at 1:04 p.m. The wall of the chase was incomplete to the fluted deck above.

45. The second floor vertical shafts were reviewed on March 3, 2010 between 8:15 and 8:35 a.m. The following deficiencies were noted:

a) the dumb waiter vertical shaft wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck, and

b) the post operation surgery area and the vertical pipe chase that passes through the area had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.

Based on observations on March 1 - 3, 2010; the facility failed to maintain the fire and smoke resistive rating of smoke/fire barriers.

Findings include:

1. On March 1, 2010 at 11:19 a.m , the first floor boiler room was observed. Fifteen electrical conduits were found that penetrated the east side of the 2 hour barrier between the boiler room and the corridor.

2. On March 1, 2010 at 11:21 a.m., the first floor boiler room south wall was observed. Eight unsealed penetrations were found.

3. The hold open device was reviewed on the second floor west doors of the two hour fire barrier on March 1, 2010 at 12:27 p.m. The metal cover was missing which would not allow the corridor wall to resist the passage of smoke.


4. A carbon steel pipe penetrating the smoke barrier was reviewed above the door 0735 at 11:37 a.m. on March 1, 2010. A gap existed around the pipe as it entered the smoke barrier above the smoke barrier doors.

5. The south smoke barrier doors on the first floor were observed on March 1, 2010 at 12:03 p.m. The hold open device cover was missing allowing no resistance to the passage of smoke to the corridor walls.

6. The hold open device was reviewed on the north doors (labeled as 0735) of the smoke barrier on first floor on March 1, 2010 at 11:33 a.m. The metal cover was missing which would not allow the corridor wall to resist the passage of smoke.

7. The two hour fire barrier was observed near the second floor elevator lobby on March 1, 2010 at 1:31 p.m. Three penetrations were found above the doors as follows:

a) a one inch hole passed through the barrier where electrical conduit or piping had been removed,

b) two electrical conduits penetrated the fire barrier and need to be sealed between the sheet rock and the conduit.

8. The two hour fire barrier in the second floor consult area contained was reviewed on March 1, 2010. Two penetrations were found through the two hour barrier.

a) a four inch fire protection pipe penetrated the wall and was not sealed between the wall and the pipe, and

b) an inch and one half fire protection pipe was not sealed between the wall and the pipe.

9. On the second floor above the smoke barrier doors labeled 0884, the wall was reviewed on March 1, 2010 at 2:13 p.m. The wall contained two unsealed penetrations:

a) one wire, and

b) one electrical conduit.

10. The second floor smoke barrier was reviewed on March 1, 2010 at 2:16 p.m. The following deficiencies were found:

a) two unsealed holes were found through the smoke barrier wall above the lay in ceiling, and

b) the fire protection wiring that ran through a sleeve was not sealed on the end.

11. At 2: 19 p.m. on March 1, 2010, the service elevator smoke curtain in the two hour fire barrier was observed. Two penetrations existed in the barrier as follows:

a) an unsealed penetration existed around the mechanism for the rolling smoke curtain, and

b) a pipe that is unsealed as it enters the 2 hour barrier.

12. The generator room was reviewed on March 1, 2010 at 2:30 p.m. A penetration through the two hour fire barrier was found related to a leak in a pipe and around a three quarter inch copper pipe. The area around the pipe was in need of repair or sealing by an approved fire stopping material.

13. The second floor smoke barrier near door 0767 was reviewed at 2:51 p.m. on March 1, 2010. The smoke barrier contained an electrical conduit that passed through it that was unsealed as it entered the barrier.

14. The second floor smoke barrier wall separating the ambulatory surgical center and the hospital was reviewed on March 1, 2010 at 3:07 p.m. A open ended sleeve passed through the east to west barrier with no wires in it. The sleeve passed through the corner of the wall as the wall changed directions to the north 90 degrees.

15. The second floor smoke barrier wall inside the security office was reviewed on March 1, 2010 at 3:22 p.m. Two water pipes entered the smoke barrier were not sealed completely. The valves on these water lines were labeled as 149 and 150.

16. The third floor day area smoke barrier was reviewed on March 1, 2010 at 3:31 p.m. An electrical conduit was found unsealed as it entered the barrier above the television.

17. The third floor smoke barrier was reviewed on March 1, 2010 at 3:36 p.m. A patch was made on the smoke barrier without the proper application of sealant on the patch. The wall contained a one inch by one and one half inch cutout that had not been sealed around after being replaced.

18. The third floor smoke barrier was reviewed on March 1, 2010 at 3:36 p.m. A hole was left in the smoke barrier where a conduit had been removed.

19. The third floor smoke barrier above the public rest room and quiet room was reviewed on March 1, 2010 at 3:48 p.m. Seven conduits passed through the barrier with thermo fiber/mineral wool around them. There were gaps around the thermo fiber/mineral wool. The same material was used to seal the wall to the fluted ceiling pan above. This material is not an acceptable smoke sealant as directed by CMS.

20. The fourth floor smoke barrier was reviewed on March 2, 2010 at 8:47 a.m. The smoke barrier hold open device, flexible electrical conduit was not properly sealed as it entered the smoke barrier above doors labeled as 0857.

21. The second floor telecommunication room was reviewed on March 2, 2010 at 10:50 a.m. The room contained at least 24 conduits with blue, brown, and white wires going into conduits for various rooms on the floor. These conduit need to be sealed to prevent the passage of smoke from one smoke compartment to the other.

Based on observation, the facility failed to install fire doors on all hazardous areas (including boiler rooms and storage rooms).

NFPA 101 Section 39.3.2.1 Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.


NFPA 101 Section 8.4.1.1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

NFPA 101 Section 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Findings include:

The main floor telecommunications room was observed at 2:05 p.m. on March 3, 2010. There was no self-closing device on the door to this hazardous room.

Based on observations made on March 1-3, 2010, the facility failed to maintain or establish the fire rated protection for a hazardous area.

The findings include:

1. The fire rated door to the General and Gynecology store room was not self-closing as observed at 1:55 p.m. on March 1, 2010. There was no self-closing devise on the door to the store room.

2. The janitors closet door at Day Surgery was observed for proper closing and latching at 3:10 p.m. on March 2, 2010. There was no self-closing devise on the store room door.

Based on observations made on March 1 - 2, 2010; the facility failed to maintain the proper door rating, allow doors with self closures from being blocked open, or to maintain the self closures for hazardous areas.

Findings include:

1. The fire rating of the engineering office door was observed on March 1, 2010. The door, labeled as 0700, is part of the one hour barrier separating the boiler room from the corridor. The door was rated at 20 minutes and should have been rated at least at 45 minutes.


2. The fire rating of the boiler room door was observed on March 1, 2010. The door, labeled as 0701, is part of the one hour barrier separating the boiler room from the corridor. The door was rated at 20 minutes.

3. Room 109 P4 was reviewed on March 1, 2010 at 12:00 p.m. The door with a self closure device was held open with a garbage can. The garbage can was removed by maintenance staff when the deficiency was discovered. The room was used as storage.

4. Room 108 was reviewed on March 1, 2010 at 12:02 p.m. The room contained storage of combustible materials. The door self closer was installed, but was disconnected.

5. On the second floor in the "Adolescent Outpatient" area, a storage room labeled with a "No Exit" sign, did not have a self closure device. The door was labeled as door 0781.

6. The second floor ambulatory surgical suite was reviewed on March 2, 2010 at 11:30 a.m. Three storage room doors in the sterile corridor were lacking a self closure mechanism.

a) door 0900 had the self closure removed,

b) door 0891 had the self closure disconnected, and

c) door 890 lacked a self closure as well.

Based on observations on March 1 - 3, 2010; the exit enclosures for two stairways were not properly rated.

Findings include:

1. The first floor stairway enclosure at the southeast stairway near the housekeeping department serves as the ground level means of egress for five stories. The door protecting this stairway shall be at least a one and one-half hour rated door. There was no label on the door protecting this stairway to attest to its fire rating as observed at 2:08 p.m. on March 1, 2010.

2. The north stairway that serves as an exit from the seventh floor Life Flight office area was being used for storage purposes as observed at 9:52 a.m. on March 2, 2010. A red tarp was found to be draped over the handrail system of the stairway at this level.

Based on observation, the facility failed to protect all vertical openings in stairways with fire rated doors with automatic self-closing devices.

NFPA 101 Section 39.2.2.3.1 Stairs complying with 7.2.2 shall be permitted.

NFPA 101 Section 7.2.2.5.1 Enclosures. All inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2. All other inside stairs shall be protected in accordance with 8.2.5.

NFPA 101 Section 7.1.3.2.1(c) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8.

Findings include:

1. The stairway to the north west mechanical room was observed at 1:30 p.m. on March 3, 2010.
a) The door at the bottom of the stairway was not a solid core door and was not self closing.
b)The door into the mechanical room at the penthouse level was also not self-closing.

2. The partial basement which was used to store medical records was observed at 2:00 p.m. on March 3, 2010.
a) The door at the main level had a louver in the door and was not self-closing.
b) There was no self closing door at the basement level separating the two levels.

Based on observations on March 1, 2010; the facility failed to complete two hour construction for the east stairwell at the second level.

According to Section 7.1.3.2.1 of NFPA 101, where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) * The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.

Finding include:

The second floor west stairwell wall construction was reviewed on March 1, 2010 at 1:38 p.m. The east side of the stairwell wall was incomplete as two hour construction. Metal studs were seen on the outside of the stairwell which is not a complete two hour separation per Section 7.1.3.2.1 of NFPA 101.

Based on observations made in the facility on March 3, 2010; the facility stored materials in stair landings which are part of the egress.

In accordance with 7.1.3.2.3 and 7.2.2.5.3 of NFPA 101, an exit enclosure, including an exit stairway, shall not have any open space within the enclosure used for any purpose (storage) that has the potential to interfere with egress.

Findings include:
The second story landing near the loading dock was observed at 11:55 a.m. on March 3, 2010. The landing area contained carts used for holding meal containers used for transporting meals to other areas much like "Meals on Wheels". Storage of items in a stair enclosure is not allowed under Section

Based on observation, the facility failed to maintain exits free of all obstructions.

NFPA 101 Chapter 39 Existing Business Occupancies 39.2.1.1 All means of egress shall be in accordance with Chapter 7 and this chapter.

NFPA 101 Chapter 7 Means of Egress, Section 7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

NFPA 101 Chapter 7 Means of Egress, Section 7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.


Findings include:

1. The south exit from Physical Therapy (PT) was observed at 11:00 a.m. on March 1, 2010. The exit was blocked by beverage canisters and a clear path was not being maintained as required.

2. The south exit from PT to the public way was observed at 11:05 a.m. on March 1, 2010. The sidewalk was not finished to the public way as it ended approximately three feet outside the building. There was approximately thirty five feet of grass to another sidewalk out near the street.

Based on observations on March 1 - 3, 2010; the facility failed to assure that a corrdior door was capable of being opened with minimal force applied.

The forces required to fully open any door manually in a means of egress shall not exceed 15 pounds of force to release the latch, 30 pounds of force to set the door in motion and 15 pounds of force to open the door to the minimum required width per Section 7.2.1.4.5 of NFPA 101. These forces shall be applied at the latch stile.

Findings include:

The second floor set of doors labeled 0764 were exercised on March 1, 2010. The panic hardware was pushed after the doors were tested for closurer. The panic bar would not realase the latching mechanism without more than 15 pounds of force.

Based on observation, the facility failed to ensure that all exit discharges were provided with illumination.


According to Section 7.9.2.1 of NFPA 101, emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6 lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

Findings include:

The south exit discharge from the second floor was reviewed on March 2, 2010 at approximately 10:00 a.m. There was no external lighting at the exit.

Based on observations made on March 1, 2010 the facility failed to maintain an exit sign to assure that when fully illuminated the letters could be plainly read.

The findings include:

An exit sign located on the south wall of the southeast portion of the Laboratory suite on the first floor showed signs of heat having affected the transparency of the material used for the letters as observed at 12:50 p.m. on March 1, 2010. The heat had darkened the material to the point where the lights behind the letters were no longer capable of illuminating them for visual purposes. Note: The placard material used for the letters on the sign was replaced after the observation was made and confirmed by the surveyor on-site.

Based on observation, the facility failed to maintain all exit signs in accordance with Section 39.2.10 of NFPA 101.

NFPA 101 Section 7.10.1.2 Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

NFPA 101 Section 7.10.5.1General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings include:

1. The exit signs were observed for illumination at 1:45 p.m. on March 3, 2010. The exit sign in X-Ray out of Suite J was not illuminated as required.

2. The exit sign in Suite H was not illuminated as observed at 1:50 p.m. on March 3, 2010.

Based on observations on March 1, 2010; the facility failed to install approved exit signage per Section 7.10.1.2 of NFPA 101.

In accordance with 7.10.1.2 of NFPA 101, exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Findings include:

The west exit from the kitchen to the corridor includes an illuminated exit sign with both of the Chevrons-Type indicators illuminated as well. The chevrons should not be removed as to avoid confusion for facility staff in an emergency. The egress is directly through the door the exit sign is above as noted on March 1, 2010 at 12:50 p.m.

Based on observations made on March 1, 2010, the facility failed to assure that a manual pull station for the fire alarm system was accessible.

The findings include:

Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible per 2-8.2.1 of NFPA 72, 1999 edition. The manual pull station located along the east wall of the kitchen area on the first floor was obstructed by the placement of carts in front of it as observed at 3:35 p.m. on March 1, 2010.

Based on observation and interview, the facility failed to maintain the fire alarm system in accordance with NFPA 72, 1999 Edition, and provide records of maintenance and service.

Findings include
NFPA 101 Section 4.6.12.2 Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

1. The fire alarm system was reviewed at 1:45 p.m. on March 3, 2010. The Fire Alarm Control Panel (FACP) was located in the northeast penthouse. The alarm panel did not identify which electrical panel supplied power for the alarm, nor was the electrical panel identified in red for the breaker which supplied power to the FACP.

A fire alarm system is not required in a Class B occupancy, but when they are installed they must be maintained as required by NFPA 101 Section 4.6.12.

2. There was no notification device (sounding device/bell) at the north east entry to the building as observed at 2:25 p.m. on March 3, 2010.

3. The FACP was observed to be in a non continuously occupied area of the northeast penthouse. A smoke/heat detector was not observed within five feet of the FACP and interconnected to the fire alarm panel.

Based on interview, the facility failed to test all smoke/heat detectors in accordance with NFPA 72.

Findings include:

1. A partial fire alarm system was in the Garden City Medical Arts Building as observed at 1:30 p.m. on March 3, 2010. When asked if the fire alarm system had received inspections, testing and maintenance since occupying the building, the maintenance staff replied that no testing of the alarm system had occurred since it was occupied.

2. The main fire alarm control panel was installed in the north east penthouse. Heat and duct detectors were installed in the building as part of the fire alarm system. Smoke and heat detectors installed as part of a fire alarm system, whether required or not, shall be maintained and tested in accordance with NFPA 72. There was no record indicating that the fire alarm system had received inspection, testing or maintenance since the building was occupied. There was no record of sensitivity testing on any heat and duct detectors since the building was occupied.

Based on observations on March 3, 2010; the facility failed to ensure that the circuit breaker controlling the fire alarm control panel (FACP) had a red marking in the designated panel identifying the fire alarm panel.

In accordance with Section 1-5.2.5.2 of NFPA 72 ,1999 edition, the connections to the light and power service for FACP shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Findings include:

On March 3, 2010 12:05 p.m., the FACP in the engineering office was examined. The FACP was labeled with the appropriate information for the circuit breaker and electrical panel that controlled the FACP as "AC Power LL- 12". When the electrical panel was reviewed, breaker #12 was not marked in red.

Based on observations and interview with maintenance staff on March 1-3, 2010, the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system.

The findings include:

In accordance with section 5-13.8.1 of NFPA 13, 1999 edition; sprinklers shall be installed under exterior roofs or combustible canopies exceeding 4 feet in width. The building is of Type I (332) construction which requires that it be protected throughout by an approved automatic sprinkler system.

1. The access space to the top of the dumb waiter shaft was observed at 8:50 a.m. on March 2, 2010. The access space measured approximately twelve feet by twenty feet and was not protected by the facility sprinkler system.



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2. The area previously used for the Bio-med department on the first floor of the building was in the process of being remodeled at the time of the survey. Two existing closets on the west side of this area did not have sprinkler protection within their confined spaces as observed at 10:52 a.m. on March 1, 2010.

3. A mechanical room was accessed through the locker room for the Laboratory personnel on the first floor of the building. The mechanical room had ductwork that exceeded four feet in width and in accordance with 5-5.5.3.1 of NFPA 13, 1999 edition sprinklers shall be installed under fixed obstructions over four feet wide such as ducts, decks, open grate flooring cutting tables, and overhead doors. Under one of the ducts that exceeds four feet in width was stored cardboard boxes, filters and foam mattresses. There was no sprinkler located under this ductwork to provide coverage for these stored items or the general area as observed at 1:10 p.m. on March 1, 2010.

4. An elevator mechanical room was accessed from the Central Processing suite on the first floor of the building. The elevator mechanical room was located on a level lower than that of the Central Processing suite and accessed by means of stairs. There was no sprinkler protection provided in the lower level area of the elevator mechanical room as observed at 3:12 p.m. on March 1, 2010.

5. The room housing the transfer switches for the emergency generators was located in a two-hour fire rated enclosure/room located off of the chiller room on the first floor of the building. The room was not protected by the sprinkler system as observed at 1:00 p.m. on March 2, 2010.

Based on observations on March 2, 2010; the facility failed to sprinkler all portions of the building.

NFPA 101 Section 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

Findings include:

The third floor "Adolescent Storage" room lacked a sprinkler head in the space. The space appeared to have changed overtime related to a medicine distribution office created on the other side of this room. This construction may have excluded the sprinkler protection for this area.

Based on observations made on March 2, 2010, the facility failed to provide for electronic supervision of sprinkler control valves.

The findings include:

The water pipe for supplying water to the fire pump and riser system originating from the fire pump was examined at 1:15 p.m. on March 2, 2010. The water supply pipe located on the first floor of the chiller room had two control valves, one on each side of the backflow device. These two control valves were provided with chains and locks as a means of securing them in the open position. There were no tamper switches attached to these two control valves to provide for electronic supervision and alarm notification of the valves when closed.

Based on review of the fire sprinkler service and testing reports on March 1-3, 2010, the facility failed to assure that the sprinkler system is maintained in accordance with the standards of NFPA 13 and NFPA 25. The facility also failed to keep the sprinkler pattern coverage free and unobstructed

The findings include:

1. The fire sprinkler service and testing reports were reviewed between 4:30 and 5:30 p.m. at the facility on March 1, 2010. There was no information in the reports which listed the static pressure or the residual pressure for the installed sprinkler system. There was evidence that all necessary monthly and quarterly reports had been done on a timely basis, but not all the required information was in the reports.



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2. The locker room for the Laboratory personnel on the first floor of the building was examined at 1:10 p.m. on March 1, 2010. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane below the sprinkler deflector or the top of storage shall be maintained with a minimum of 18 inches clearance per 5-5.5.3 and 5-5.6 of NFPA 13, 1999 edition. The majority of lockers in this room had a slanted top to prevent the storage of items on top of the lockers. The lockers which protrude from the wall into the center of the room had flat tops and personal items were stored on top of the lockers. The items were within 18 inches of the sprinkler head in this location and obstructed the coverage pattern of that sprinkler.

3. The sprinkler service and inspection reports for the building were reviewed between 4:30 and 5:30 p.m. on March 1, 2010. An anti-freeze loop was installed and the valve and testing piping for that system was located in a room adjacent to the power lift assembly in the first floor maintenance area suite. The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary per 2-3.4 of NFPA 25, 1998 edition. The antifreeze solution shall be prepared with a freezing point below the expected minimum temperature for the locality per 4-5.2.3 of NFPA 13, 1999 edition. There was no documentation found that noted the gravity (rating) of the anti-freeze in that loop to assure that it was of sufficient strength to prevent freezing.

4. The penthouse housing the elevator mechanical room accessed from a stairway by the seventh floor Life Flight helicopter offices was examined at 9:50 a.m. on March 2, 2010. Sprinkler piping or hangers shall not be used to support nonsystem components per 6-1.1.5 of NFPA 13. 1999 edition. Grounding wires were found to be attached to the sprinkler piping in this room.

Based on observations made from March 1 - 3, 2010; the facility failed to maintain the sprinkler system components in accordance with the standards of NFPA 13 and NFPA 25.

In accordance with Section 2-2.1.1 of NFPA 25, 1998, sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.


Findings include:

1. An escutcheon ring was found to be missing in Room 104 on March 1, 2010.

2. On March 1, 2010 at 12:29 p.m. inside the first floor mens bathroom, an escutcheon ring was found to be missing on a sprinkler head located near a florescent light.

3. An escutcheon ring was found missing inside the first floor elevator mechanical room at 12:43 p.m. on March 1, 2010.

4. An escutcheon ring was found missing inside room 368, elevator mechanical or telecommunication room. This third floor room was reviewed at 3:56 p.m. on March 1, 2010.

5. The fire sprinkler service and testing reports were reviewed between 4:30 and 5:30 p.m. at the facility on March 1, 2010. There was no information in the reports which listed the static pressure or the residual pressure for the installed sprinkler system. There was evidence that all necessary monthly and quarterly reports had been done on a timely basis, but not all the required information was in the reports.

6. On March 2, 2010 at 9:10 a.m. in the fourth floor "Gym", an escutcheon ring was found to be missing.

7. On March 2, 2010 at 10:31 a.m. the staff area in Outpatient area was reviewed. An escutcheon ring was missing for a sprinkler head in the room.

8. On March 3, 2010 at 11:50 a.m., the doctors entrance to the ambulatory surgical center was lacking an escutcheon ring.

Based on observation, the facility failed to maintain all portable fire extinguishers in accordance with NFPA 10.

NFPA 101 Section 39.3.5 Extinguishment Requirements. Portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. (See also Section 39.4.)

NFPA 101 Section 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Findings include:

A portable fire extinguisher located in the northeast penthouse was observed for proper maintenance at 1:45 p.m. on March 3, 2010. The fire extinguisher had been placed in service in 1995 and carried a identification of GCMP#1. The next hydo test was in 2008, thirteen years after being placed in service. There was no tag identifying that the extinguisher had received a six year maintenance test, in 2001 or the twelve year hydro test required in 2007.

Based on observations made on March 1-3, 2010, the facility failed to assure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

The findings include:

Fire extinguishers shall be hydrostatically retested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

1. The second floor Kitchen penthouse was observed at 10:05 a.m. on March 1, 2010. The portable fire extinguisher was not hung as required, but was resting on the penthouse floor. The same fire extinguisher had not been serviced annually since 1999.

2. The second floor Day Surgery penthouse was observed at 10:20 a.m. on March 1, 2010. There was no portable fire extinguisher in the Day Surgery penthouse as required.

3. The electrical room of Emergency Room (ER) was observed at 12:50 a.m. on March 1, 2010. The portable fire extinguisher in the electrical room was not mounted to the wall and had not been serviced annually since September of 2008.

4. The dry chemical portable fire extinguisher located in the corridor of Operating Room (OR) was examined at 2:05 p.m. on March 1, 2010. The label attached to the extinguisher noted that it had received a six year inspection in 1996. The extinguisher was due for its hydrostatic test in 2002. The extinguisher did not receive a hydrostatic test or the second six year maintenance test until 2004. There was no collar on the extinguisher to distinguish that the cylinder had been emptied and recharged.

5. A dry chemical portable fire extinguisher located in the International Heart Institute (IHI) waiting room was examined at 3:02 p.m. on March 1, 2010. The extinguisher received a six year maintenance in 2000, and was to receive a second six year maintenance in 2006, but it did not get done until 2007. The extinguishers sticker did not indicate that it had been hydrotested after twelve years and it did not have a collar indicated that it had either.


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6. The dry chemical portable fire extinguisher located in the area that was previously the Bio-med room on the first floor was examined at 11:00 a.m. on March 1, 2010. The extinguisher was manufactured in 1987. The only testing label attached to the extinguisher noted that a six-year test was done in 2007. There was no documentation as to when the last twelve-year hydrotest (due in 1999) was performed on the cylinder.

7. The dry chemical portable fire extinguisher located in the corridor by Conference room A on the first floor was examined at 8:45 a.m. on March 2, 2010. The extinguisher was manufactured in 1996. The only testing label attached to the extinguisher noted that a six-year test was done in 2007. There was no documentation as to when the last twelve-year hydrotest (due in 2008) was performed on the cylinder. Nor was there a label attesting that the initial six-year test had been performed in 2002.

8. The dry chemical portable fire extinguisher located across from the staff break room in the Laboratory suite on the first floor was examined at 8:50 a.m. on March 2, 2010. The extinguisher was manufactured in 2001. The only testing label attached to the extinguisher noted that a six-year test was done in 2008. This test should have been performed in 2007 to conform to the six-year period required.

9. The dry chemical portable fire extinguisher located in the penthouse housing the elevator mechanical room accessed from a stairway by the seventh floor Life Flight helicopter offices was examined at 9:50 a.m. on March 2, 2010. The extinguisher was manufactured in 1982. Two testing labels were attached to the extinguisher noting that a six-year test was done in 1995 and that a combination six-year and twelve-year hydrotest were done in 2008. There was a gap in documentation between the six-year test in 1995 and the next required test (hydrotest due in 2001). According to the labels attached, the extinguisher went a period of thirteen years between the next required testing dates.

10. The dry chemical portable fire extinguisher located in the corridor across from the Credit Union office on the first floor was examined at 11:31 a.m. on March 2, 2010. The extinguisher was manufactured in 1984. Two testing labels were attached to the extinguisher noting that a six-year test was done in 1996 and that a twelve-year hydrotest were done in 2005. There was a gap in documentation between the six-year test in 1996 and the next required test (hydrotest due in 2002). According to the labels attached the extinguisher went a period of nine years between the next required testing dates.

Based on observations on March 1-3, 2010, the facility failed to assure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

Fire extinguishers shall be hydrostatically retested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

Findings include:

The extinguishers throughout the building were missing proof of the 6 year test as required per Table 5-2 of NFPA 10.

Based on observations made on March 1 - 3, 2010; the facility failed to maintain adequate means of egress. The means of egress from the storage area in the basement area was reduced in size by storage of kitchen related items.

According to Section 7.1.10.1 of NFPA 101; means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings include:

1. The first floor, north kitchen storage area was reviewed at 11:41 a.m. on March 1, 2010. Two deficiencies were noted:

a) Several kitchen related items; food warmers, metal racks, plastic garbage bins, etc., were stored in the exit reducing width of egress.

b) The gate on the west side of the elevator door in the storage room was locked with a keyed lock.

2. During the fourth floor fire drill on March 3, 2010 at approximately 11:00 a.m., a handwashing stand was noted as being in the corridor as the fire drill occurred. This item will have to be located in an area where it will not reduce the width of the corridor or hung on the wall.

3. On the third floor on March 3, 2010 at approximately 11:30 a.m., a fire drill was performed. Four chairs were noted to be in the corridor and were used for new patients as they are admitted as indicated by staff. These chairs need to moved out of the egress corridor to a location that does not reduce the width of the corridor.

Based on observations made on March 2, 2010; the facility failed to provide documentation or proof that draperies, cubicle curtains, etc. were fire retardant as required.

According to Section 10.3.1 of NFPA 101; where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Findings include:

1. The fourth floor "gym" was reviewed on March 2, 2010 at 9:10 a.m. Two curtains used to separate space were found to not be labeled to indicate they meet NFPA 701 as being flame resistant. When asked, the maintenance staff could not provide documentation that these curtains meet NFPA 701.

2. The second floor counselors file room 2 was observed on March 2, 2010. There were no tags indicating the flame resistance of two curtains hung in the room. When asked the maintenance staff could not provide documentation that they meet NFPA 701.

3. The second floor mission leadership office was reviewed. There were no tags indicating the flame resistance of curtains hung in the room. When asked the maintenance staff could not provide documentation that they meet NFPA 701.

4. The second floor ambulatory surgical suite was reviewed on March 2, 2010 at 11:03 a.m. Two curtains were found in the suite that were not tagged indicating their flame resistance. When asked the maintenance staff could not provide documentation that they meet NFPA 701.

Based on observations made on March 1, 2010, the facility failed to maintain the medical gas or compressed gas systems and cylinder storage areas in conformance with the standards of NFPA 99, 1999 edition.

The findings include:

1. The medical gas manifold and storage room was located off of the loading dock on the south end of the first floor of the building. Freestanding or unsecured cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down per 8-3.1.11.2(h) and 4-3.5.2.1(b27) of NFPA 99. An "E" size cylinder of oxygen was observed to be unsecured and lying on the floor surface of this room at 2:10 p.m. on March 1, 2010.

2. The medical gas manifold and storage room was located off of the loading dock on the south end of the first floor of the building. In any storage location housing nonflammable gases the electric wall fixtures, switches, and receptacles in that enclosure shall be installed in fixed locations not less than 5 feet above the floor as a precaution against their physical damage per 4-3.1.1.2(a)4 of NFPA 99. The light switch in this room was measured and found to be four feet from the floor surface as observed at 2:10 p.m. on March 1, 2010.

3. A hazardous materials room containing other pressurized gases was adjacent to the medical gas manifold and storage room located off of the loading dock on the south end of the first floor of the building. This room was separated by one-hour construction from other portions of the building. Storage of flammable and nonflammable gases in cylinders shall comply with 4-3.1.1.1 and 10-10.2.1 of NFPA 99. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. A free-standing cylinder of Ethanol (flammable gas) and a free-standing cylinder of Carbon Dioxide (nonflammable gas) were observed at 2:15 p.m. on March 1, 2010 in this room.

Based on observations made on March 1, 2010, the facility failed to maintain the medical gas or compressed gas systems and cylinder storage areas in conformance with the standards of NFPA 99, 1999 edition.

In any storage location housing nonflammable gases, the electric wall fixtures, switches, and receptacles in that enclosure shall be installed in fixed locations not less than 5 feet above the floor as a precaution against their physical damage per 4-3.1.1.2(a)4 of NFPA 99.

Findings include:

The medical gas manifold and storage room is located off of the loading dock on the north east corner of the building of the second floor. The light switch in this room was observed at 12:10 p.m. on March 1, 2010 and was not at five feet.

Based on observations made on March 3, 2010, the facility failed to assure that a cylinder of oxygen was properly secured from falling over or being knocked down. In addition, three R-22 refrigerant tanks were stored in a mechancial room.

Freestanding cylinders of nonflammable gases such as oxygen, shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down (Section 8-
3.1.11.2(h) and 4-3.5.2.1(b) of NFPA 99, 1999 edition).

The findings include:

1. An "E" size cylinder of oxygen was found to be freestanding at the bottom of the stairway which leads to a roof top store room as observed at 1:00 p.m. on March 3, 2010.

2. Three R-22 refrigerant cylinders were located in the northwest mechanical penthouse as observed at 1:45 p.m. on March 3, 2010. R-22 refrigerant gas is combustible by nature and should not be stored in the penthouse space.

Based on observation, the facility failed to maintain electrical wiring and equipment in accordance with NFPA 70.

Extension cords, including power strips or multiple adaptors, used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction. One means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, 1999 edition and 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99, 1999 edition. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle and not connected in series or "daisy chained".

NFPA 70, Article 110-26 states that ufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches, whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26. Working space required by this Article shall not be used for storage.

NFPA 70, Article 384-13 requires that all panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors. NFPA 70, Article 110-22. Identification of Disconnecting Means states that each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

Findings include:

1. An orange extension cord was found in use in the northeast penthouse as observed at 1:20 p.m. on March 3, 2010.

2. There were two multi-plug adaptors found in use in the northeast penthouse as observed at 1:21 p.m. on March 3, 2010.

3. There were two surge protected cords found in series (plugged one into the other) in the northeast penthouse.

3. A brown extension cord was in use for a ceiling light in the northwest penthouse as observed at 1:45 p.m. on March 3, 2010.

4. Two extension cords were found in use along the east wall of the telecommunications room as observed at 1:50 p.m. on March 3, 2010.

5. Stored items were located in front of the electrical panels of the telecommunications room as observed at 1:51 p.m. on March 3, 2010.

6. Stored items were located in front of the main electrical panel in the basement as observed at 2:00 p.m. on March 3, 2010.

Based on observations made on March 1-3, 2010, the facility failed to maintain the electrical system or its components in accordance with the standards of NFPA 70, NFPA 99 and/or CMS interpretations.

The findings include:

Extension cords including power strips or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction. One means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, 1999 edition; 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99, 1999 edition; and interpretations from th Centers for Medicare and Medicaid. (CMS). The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle. No overcurrent device shall be connected in series or "daisy chained" with any conductor that is intentionally grounded per Article 240-22 of NFPA 70, 1999 edition.

1. The gift shop electrical system was observed at 11:50 a.m. on March 1, 2010. One extension cord was found in use in place of permanent wiring.

2. The Tissue Engineering Lab in the International Heart Institute was reviewed for electrical problems at 2:55 p.m. on March 1, 2010. An extension cord was found in use in place of permanent wiring.

3. The elevator mechanical room on the sixth floor behind the sleeping quarters for the heliport personnel was observed at 9:35 a.m. on March 2, 2010. There were two orange extension cords in use in place of permanent wiring.



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4. The electrical room housing the anti-freeze sprinkler control piping within the engineering suite on the first floor was examined at 10:30 a.m. on March 1, 2010. Two machines for cleaning out pipes were parked directly in front of panel boards IRE2 and IRE3. The width of the working space in front of electrical equipment shall be the width of the equipment or 30 inches, whichever is greater per 110-26 of NFPA 70, 1999 edition. The work space shall permit at least a 90 degree opening of equipment doors or hinged panels and shall not be used for storage. The two machines parked in front of the panel boards infringed on the work space required for access to that electrical equipment.

5. The bathroom located in the previous Bio-med suite on the first floor was examined at 10:54 a.m. on March 1, 2010. The GFCI receptacle in this room was tested by both means of its self testing buttons and an independent testing instrument. When tested the GFCI receptacle failed to reset. Note: The GFCI receptacle was replaced with a new one after the observation was made and confirmed by the surveyor while on-site.

6. A mechanical room was accessed through the locker room for the Laboratory personnel on the first floor of the building. Numerous items and boxes were parked or stored directly in front of panel board 1EPE and four other master switches/breakers on a north wall of this room as observed at 1:06 p.m. on March 1, 2010. These items infringed on the work space required for access to that electrical equipment

7. The bathroom located in the Central Processing suite on the first floor was examined at 3:05 p.m. on March 1, 2010. The GFCI receptacle in this room was tested by both means of its self testing buttons and an independent testing instrument. When tested the GFCI receptacle failed to reset.


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8. The fifth floor fire barrier was reviewed on March 2, 2010 at 11:17 a.m. Above the doors, a junction box was found that was missing a cover.

Based on observations made from March 1 to 3, 2010; the facility failed to meet the requirements of NFPA 70, National Electrical Code, 1999 edition.

In accordance with Article 110-26 of NFPA 70; sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches, whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26. Working space required by this Article shall not be used for storage.

According to Article 384-13 of NFPA 70; all panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors. NFPA 70, Article 110-22. Identification of Disconnecting Means states that each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

According to Article 517-20 of NFPA 70; all receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption of power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.

Findings include:

1. On the second floor in the telecommunication room, an electrical junction box was found to not have a cover in place. The cover was in the same area and was replaced by the maintenance staff at the time of survey.

2. On the second floor in the generator room, the electrical panel schedule for "Panel 1E" was reviewed at 2:31 p.m. The panel was not current as breakers were on with no indication what they were for on the panel schedule.

3. On the second floor in the generator room, the electrical panel schedule for "Panel ID" was reviewed at 2:31 p.m. on March 2, 2010. The panel was not current as breakers were on with no indication what they were for on the panel schedule.

4. The third floor patient laundry area used for rehabilitation purposes, did not include a ground fault circuit interrupter (GFCI) for an outlet near the sink. The outlet and cover plate were red in color.

5. On the fourth floor in electrical panel labeled "Panel 3A" some circuits in the panel were on but there was no label for what they controlled. This observation was made on March 2, 2010 at 9:20 a.m.

6. The first floor storage area was reviewed on March 3, 2010 at 9:55 a.m. Several items were stored in front of the electrical panel in the storage area including a two portable fans, an infectious waste stand, a plant, and a cardboard box.

7. On the second floor in room 206 there were two electrical panels with panel schedule needing to be updated. The panels were labeled as "Panel 1A and 1B".

8. On the second floor in room 206, there were items stored in front of the electrical panels. Items included a rocking chair and hospital bed rolling tray.

9. On the second floor in the Adolescent Out Patient area, there were two panels in need of updates to the panel schedules. The panels were labeled as panel 1LH and 1CH.

10. Room 205 on the second floor was reviewed on March 2, 2010 at 10:47 a.m. The room contains a sink that has an electrical outlet within near the sink. The electrical outlet lacked the proper GFCI protection.

Based on review of the fire plan on March 3, 2010; the facility failed to have a fire watch policy which included that the authority having jurisdiction (State Agency) shall be contacted whenever it was instituted.

In accordance with Section 9.7.6.1 of NFPA 101; where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the fire plan was provided to the survey team and was reviewed at 7:30 a.m. on March 3, 2010. The fire watch policy addressed the procedures to be followed whenever the automatic sprinkler system was out of service for more than 4 hours in a 24-hour period. However, the fire watch policy did not specifically include notification of the State Agency at 406-444-4170 whenever the sprinkler system was out of service for longer than 4 hours in 24 hour period

Based on review of the fire plan, the facility failed to have a fire watch policy which included that the authority having jurisdiction (State Agency) shall be contacted whenever it was instituted.

In accordance with the Section 9.7.6.1of NFPA 101 of the 2000 Edition; where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the fire plan was provided to the survey team and was reviewed at 7:30 a.m. on March 3, 2010. The fire watch policy addressed the procedures to be followed whenever the automatic sprinkler system was out of service for more than 4 hours in a 24-hour period. However, the fire watch policy did not specifically include notification of the State Agency at 406-444-4170 whenever the sprinkler system was out of service for longer than 4 hours in 24 hour period

Based on review of the fire plan on March 3, 2010; the facility failed to have a fire watch policy which included that the authority having jurisdiction (State Agency) shall be contacted whenever it was instituted.

In accordance with Section 9.6.1.8 of NFPA 101; where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the fire plan was provided to the survey team at 7:30 a.m. on March 3, 2010. The fire plan did have a fire watch policy that addressed the procedures to be followed whenever the fire alarm system was out of service. The policy did not specifically include notification of the State Agency at 406-444-4170 whenever the fire alarm system was out of service for more than 4 hours in a 24 hour period.

Based on review of the fire plan, the facility failed to have a fire watch policy which included that the authority having jurisdiction (State Agency) shall be contacted whenever it was instituted.

In accordance with Section 9.6.1.8 of NFPA 101, 2000 Edition, where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the fire plan was provided to the survey team at 7:30 a.m. on March 3, 2010. The fire plan did have a fire watch policy that addressed the procedures to be followed whenever the fire alarm system was out of service. The policy did not specifically include notification of the State Agency at 406-444-4170 whenever the fire alarm system was out of service for more than 4 hours in a 24 hour period.

Based on observations made on March 1, 2010, the facility failed to assure that Alcohol Based Hand Rub (ABHR) dispensers were not installed over an ignition source.

The findings include:

An ABHR dispenser was installed directly above two light switches adjacent to the south corridor door from the "dirty side" room of the first floor Central Processing suite as observed at 2:50 p.m. on March 1, 2010.

Based on observations made on March 1, 2010; the facility failed to place Alcohol Based Hand Rub (ABHR) dispensers away from ignition sources.

Guidance issued by the Centers for Medicare & Medicaid Services (CMS) in Survey and Certification Letter (S&C 05-33) issued in June 9, 2005 indicates that "dispensers shall not be installed over or directly adjacent to an ignition source." Directly adjacent has been interpreted to be one inch.

Findings include:

Room 100 was reviewed on March 1, 2010. An ABHR was mounted within one inch directly above the electrical switch for the room lighting. The ABHR contained 62% ethyl alcohol.

Based on observation, the facility failed to provide an astragal on a 1.5 hour rated fire door which separates a nonconforming building from a health care facility, failed to fill penetrations in wall between nonconforming buildings, failed to complete walls where nonconforming buildings attach to a health care facility, and failed to properly label all fire doors between health care facilities and nonconforming buildings.

Findings include:

1. The set of fire doors which separate the Womens Health Center in the hospital building from the Broadway Building were reviewed at 9:35 a.m. on March 1, 2010. The 1.5 hour rated fire doors did not have an astragal affixed to either door. There was a space between the doors of approximately one quarter inch when the doors were in the closed position. Fire doors can not have a space greater than one eighth inch when in the closed position.

2. The two hour barrier wall on second floor of the hospital was observed at 2:45 p.m. on March 2, 2010. The wall above the set of double doors at the two hour wall had one inch penetration of the wallboard which was not sealed.



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3. The set of corridor doors adjacent to the Student study room (across the hall from the Laboratory) on the first floor was shown as being part of a two-hour fire barrier on the floor plans of the building. One of the two doors did not have a label attesting to it being at least a one and one-half hour rated door for use in openings in fire barriers as observed at 2:31 p.m. on March 1, 2010. Note: The other door did have a one and one-half hour label on it.



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4. The second floor two hour barrier between the hospital and the Broadway building was reviewed on March 3, 2010 between 8:02 a.m. and 8:11 a.m. The following deficiencies were found:

a) a disconnected, open ended electrical conduit was found that penetrated the barrier,

b) the right hand side of the wall was incomplete from the wall to the ceiling pan above door 0169 from the Broadway building going into the hospital, and

c) the right hand side of the wall was incomplete from the wall to the ceiling pan above door 0169 from the Hospital into the Broadway building.

Based on observation on March 1, 2010; the facility failed to maintain proper clearances for a set of two hour doors and failed to maintain a two hour barrier between the hospital and a nonconforming occupancy (ambulatory surgical center).

According to NFPA 80, 1999 Edition, 2-3.1.7 the clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. ± 1/16 in. (3.18 mm ± 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.

Findings include:

1. The set of two hour fire doors entering into the waiting area of the ambulatory surgery center left a gap of greater than 1/8 inch when closed. Fire doors cannot have space greater than one eighth inch when in the closed position.


2. The second floor two hour fire barrier east of the elevator lobby and stair well was observed on March 1, 2010 at 1:43 p.m. The fire barrier contained at least two electrical conduits that passed through into the ambulatory surgical center. A open space between the corridor wall and the concrete wall above contained an open area where the electrical conduit passed.

Based on observations made on March 1-2, 2010, the facility failed to maintain the fire and smoke resistance rating of ceiling and wall assemblies.

The findings include:

1. The ceiling tile in Day Surgery on the second floor of the hospital was observed at 11:30 a.m. on March 1, 2010. There were approximately eight penetrations in the ceiling tile where the old telemetry system had been removed, these were approximately 3/4 inch in diameter each.

2. The utility room in the Emergency Room was observed at 1:05 p.m. on March 1, 2010. There were approximately fifteen 1/2 inch penetrations in the back wall where some shelving had been removed.

3. The janitors closet at Day Surgery was observed at 3:10 p.m. on March 2, 2010. The ceiling tile was missing in this room, exposing an unprotected area to the ceiling cap above.



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4. The housekeeping department storage room located at the southeast corner of the first floor of the building was examined at 1:50 p.m. on March 1, 2010. Removal of one or more panels in a lay-in ceiling have the potential to hinder the ability of the sprinkler installed in that type of ceiling assembly to activate by allowing heat and smoke to enter into interstitial spaces and collect there, delaying the activation of the sprinkler to control the fire and the fire alarm system to activate. One large ceiling tile being two feet by four feet and two other smaller size tiles were observed to be out of place in the ceiling assembly of this room.

5. The enclosure housing the sterilizer units on the first floor of the building was examined at 2:21 p.m. on March 1, 2010. Removal of any section of a monolithic ceiling has the potential to hinder the ability of the sprinkler installed in that type of ceiling assembly to activate by allowing heat and smoke to enter into interstitial spaces and collect there, delaying the activation of the sprinkler to control the fire and the fire alarm system to activate. A section of the monolithic ceiling assembly measuring approximately 20 inches by 20 inches had been removed and was open to the interstitial space above.

6. An elevator mechanical room was accessed from the Central Processing suite on the first floor of the building and examined at 3:12 p.m. on March 1, 2010. The elevator mechanical room was located on a level lower than that of the Central Processing suite and accessed by means of stairs. An open penetration in the wall of this room for the hydraulic piping serving the elevator was observed and needs to be sealed with fire rated material.

7. The telephone service room on the first floor of the building located between the two banks of elevators was examined at 3:55 p.m. on March 1, 2010. Two ceiling tiles were observed to be out of place in the ceiling assembly.

Based on observations made on March 1-3, 2010, the facility failed to maintain the fire and smoke resistance rating of ceiling and wall assemblies.

Holes or missing tile in the ceiling assembly have the potential to hinder the ability of the sprinkler system installed to activate by allowing heat and smoke to enter interstitial spaces and collect there, delaying the activation of the sprinkler to control the fire and the fire alarm system to activate.

Findings Include:

1. Room 107 P3 on the first floor was reviewed on March 1, 2010 at 12:15 p.m. A camera cable entered the ceiling tile that was not sealed to the rated ceiling assembly.

2. Room 105 on the first floor was reviewed on March 1, 2010 at 12:21 p.m. One piece of ceiling tile had a quarter inch gap along the tile length between the ceiling tile and the suspended ceiling grid.

3. The men's bathroom on first floor was reviewed on March 1, 2010 at 12:25 p.m. Ceiling tile in the bathroom were damaged or had holes in them.

4. The women's bathroom on first floor was reviewed on March 1, 2010 at 12:25 p.m. Ceiling tile in the bathroom were damaged or had holes in them.

5. The first floor elevator mechanical room was observed on March 1, 2010 at 12:43 p.m. There were a total of 24 penetrations through the ceiling assembly that need to be sealed to the passage of smoke.

6. The first floor kitchen was reviewed at 12:53 p.m. on March 1, 2010. An abandoned electrical box was found with no cover near a desk. The box should be covered to resist the passage of smoke to other smoke compartments.

7. The second floor telecommunication room was reviewed on March 1, 2010 at 2:02 p.m. Holes in the ceiling tile were observed as follows:

a) a ceiling tile was in place that had a speaker removed leaving an approximately 12 inch by 12 inch hole, and

b) pipes and electrical wiring entered the ceiling assembly and were not sealed to resist the passage of smoke.

8. The second floor Adolescent Out Patient store room contained ceiling tile that had been water damaged in the lay in ceiling while some had been removed as noted on March 2, 2010.

9. The second floor telecommunication room was reviewed on March 2, 2010 at 10:50 a.m. There were penetrations of the ceiling assembly as follows:

a) at least 24 conduits with blue, brown, and white wires going to various rooms on the floor which were not sealed to prevent the passage of smoke from one smoke compartment to the other, and

b) the ceiling assembly was not complete to the conduits.

10. Room 368, the third floor elevator communicating room, was observed on March 1, 2010. The ceiling tile was incomplete or unsealed items penetrated the ceiling tile in various locations as follows:

a) unsealed conduits entered the rated ceiling assemble, and

b) where a sprinkler head missing a escutcheon ring entered the ceiling assembly damage was done to the ceiling tile.

11. In the third floor storage room where the shredder bin is housed, an escutcheon ring was found with a hole larger than required around the ceiling tile. The tile was not laying with in the ceiling assembly completely as observed on March 1, 2010 at 4:42 pm.


12. In the fourth floor "Gym", the copper pipes supplying the reheat coil were observed on March 2, 2010. The copper pipes, as they entered the ceiling tile, were not sealed.

Based on observation, the facility failed to provide documentation that all interior wall finishes comply with Section 10.2.3 of NFPA 101 Chapter 39 Existing Business Occupancies in all exit ways and corridors.

NFPA 101 39.3.3.1 Interior finish shall be in accordance with Section 10.2.

NFPA 101
10.2.3.2* Products required to be tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale.

Findings include:

There is a large amount of wood (cedar) used on the wall finishes in the exit ways of the building. Maintenance staff were not certain that the walls had been sprayed with a material to meet Class A or Class B finish requirements.

Based on observations and interviews with nursing and maintenance staff made on March 1-3, 2010, the facility failed to assure that there were no impediments to closing and latching corridor doors.

In accordance with section 19.6.6.3.3 of NFPA 101, 2000 edition; doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close.

The findings include:

1. A bladder scanner was observed to be blocking the door from closing the corridor door to Medical Intensive Care Unit (MICU) on the third floor of the hospital as observed at 2:20 p.m. on March 1, 2010.



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2. There are two doors opening onto the west exit corridor from the Pharmacy on the first floor of the building. One of the two corridor doors was no longer in use as observed at 2:38 p.m. on March 1, 2010. A shelf with supplies had been placed against this opening into the corridor system.

3. A cart storage room located off of what was described as the "dirty side" of central processing had a door opening onto the west exit corridor. Wheeled red carts were placed against this opening into the corridor system.

Based on observations on March 1 - 3, 2010; the facility had a corridor door that would not resist the passage of smoke and did not provide a dutch door with an astragal.

According to Section 19.3.6.3.6 of NFPA 101, Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows.

Findings include:

1. The second floor of "Outpatient" was received on March 2, 2010 at 10:25 a.m. The door to the social workers office had at least three unsealed, one quarter inch holes where previous door hardware had been located.

2. The third floor medication dispensing station, dutch door was reviewed during the fire drill on March 3, 2010 at approximately 11:00 a.m. The door did not contain an astragal as required.

Based on observation, the facility failed to protect all vertical openings between floors as required by Sections 39.3.1.1, and 39.3.1.2 of NFPA 101 Chapter 39 Existing Business Occupancies.

NFPA 101 Section 39.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

NFPA 101 Section 8.2.5.4 The fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four stories or more in new construction - 2-hour fire barriers
(2) Other enclosures in new construction - 1-hour fire barriers
(3) Existing enclosures in existing buildings - 1/2-hour fire barriers

NFPA 101 Section 39.3.1.2 Floors below the street floor used for storage or other than business occupancy shall have no unprotected openings to business occupancy floors.


Findings include:

1. The north east mechanical penthouse was observed at 1:30 p.m. on March 3, 2010.

a) There were three openings in the north wall to the level below around electrical wiring.

b) There were five openings in the west wall of the mechanical room into the stairway for electrical wiring and open conduits.

c) There were three holes in the wall where the Fire Alarm Control Panel (FACP) was located, these were open to the level below.

d) There were two holes in the adjoining wall for the atrium around pipes/conduits.

e) There were seven openings in the wall between the stairway and the north east penthouse for communication wire.

2. The north west mechanical penthouse was observed at 1:40 p.m. on March 3, 2010.

a) There is a hole in the adjoining wall to the medical center which was open.

3. The southwest mechanical penthouse was observed at 1:50 p.m. on March 3, 2010.

a) There were five conduit openings in the floor of the penthouse which were open to the level below.

b) There were three vertical openings for communication wiring which were open to the level below.

c) There were three open penetrations in the north wall of the penthouse which were open to the atrium of the medical center.

4. The partial basement of the medical center was observed for vertical opening at 2:00 p.m. on March 3, 2010. There is a penetration around a vent in the stairway leading to the basement.

Based on observations made on March 1, 2010, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 edition, pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

The Information Technology (IT) room on second floor of the hospital was observed at 11:20 a.m. on March 1, 2010. There was one penetration from this room to the level below (first floor cafeteria).

Based on observations which were made during a tour of the building on March 1-3, 2010, it was determined that the facility did not ensure that all doors requiring self closing hardware were closed or could close to positive latching.

Findings include:

1. The fire door (labeled 0510) on fifth north of the hospital did not latch when exercised at 7:50 a.m. on March 2, 2010.

2. The fire door to the dumb waiter access on sixth floor of the hospital did not latch as the spring had been removed and it would not self-close as required at 8:50 a.m. on March 2, 2010.



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3. A supply/storage room within the first floor maintenance suite was shown as being enclosed by one-hour construction on the floor plans of the building. The fire rated door into this supply/storage room had a chock holding it open as observed at 10:10 a.m. on March 1, 2010. There was no one occupying or using the supply/storage room at the time of the observation and the chock inhibited the self-closure mechanism on the fire door from closing and latching the door.

4. The maintenance suite area on the first floor was separated from an exit stairway to the second floor by a set of fire doors in the immediate area of the power lift assembly. A movable/wheeled bed was placed in the doorway of these fire doors as observed at 10:24 a.m. on March 1, 2010. The placement of the bed would inhibit the doors from closing and latching upon their release from the magnetic hold devices in case of an emergency. Note: The bed was removed from the doorway after the observation was made and confirmed by the surveyor while on-site.

5. The northeast exit stairway accessed from the second floor of the boiler room suite was examined at 1:10 p.m. on March 2.2010. The one and one-half hour rated door was being held open by a chock which inhibited the door from self-closing and latching.

Based on observations on March 1 - 3, 2010; it was determined that the facility did not ensure that all doors requiring self closing hardware were closed or could close to positive latching.

Findings include:

The second floor two hour barrier corridor was reviewed on March 1, 2010 at approximately 1:00 p.m. The set of fire doors labeled as 0745 were in need of adjustment based on three attempts to allow the door to close to positive latching. The door would not latch during each of the three attempts.

Based on observations, the facility failed to maintain the fire and smoke resistive rating of smoke/fire barriers.

Findings include:

1. The electrical room in the Emergency Room (ER) was observed at 12:55 a.m. on March 1, 2010. There were three penetrations along an I beam along the corridor wall which were not sealed.

2. The two hour wall between the ambulance garage and the paramedics charting room was observed at 11:45 a.m. on March 2, 2010. Two unsealed sleeve penetrations were found through the south wall for communication wiring.

3. The soiled utility room in the E.R. was observed at 11:50 a.m. on March 2, 2010. Two penetrations were found in the east wall, one in the south wall, and one in the west wall. All penetrations were for communication wiring.

4. The locker room in the E.R. was observed at 1:00 p.m. on March 2, 2010. Two penetrations were found in the north wall, one was an open three inch sprinkler pipe, and the other was a three quarter inch conduit that was open.

5. The E.R. exit foyer was observed at 1:10 p.m. on March 2, 2010. Seven penetrations were found in the east wall above the exit door at the two hour wall.

6. The east corridor wall outside of E.R. was examined at 1:12 p.m. on March 2, 2010. One three inch sprinkler pipe had not been sealed above the fire extinguisher cabinet.

7. The north wall at the double doors into Radiology was examined at 1:30 p.m. on March 2, 2010. One penetration was found in the wall above the double doors.

8. The wall was examined above the double doors into X-Ray at 1:32 p.m. on March 2, 2010. Two sleeves extending through the wall were not sealed at the end of the sleeves.

9. The east wall, near X-Ray, across from smoke detector LO3D42, was examined at 1:35 p.m. on March 2, 2010. There was a one and one half inch hole in the wallboard which was not sealed.

10. The smoke barrier wall at the X-Ray reading room was examined at 1:40 p.m. on March 2, 2010. A three inch conduit leading to a cable tray was not sealed at the smoke barrier wall.

11. The smoke barrier wall separating X-Ray from the corridor was examined at 1:50 p.m. on March 2, 2010. A sprinkler collar penetrated the wallboard on the east wall to X-Ray, exposing a hole in the wallboard around the collar.

12. The two hour wall at the second set of service elevators was examined at 2:00 p.m. on March 2, 2010. There were five penetrations of the fire wall above the set of fire rated doors.

13. The east wall of Post-Operations was examined at 2:05 p.m. on March 2, 2010. One two inch conduit was not sealed at this location along with a phone box cover missing which had branch lines extending through the same wall.

14. The smoke barrier wall at the entrance to Surgery was examined at 2:10 p.m. on March 2, 2010. A communications cable tray was not sealed at the smoke barrier wall above the doors to Surgery.

15. The smoke barrier wall at Surgery was examined at 2:15 p.m. on March 2, 2010. A three inch sewer pipe was not sealed as it passed through the north wall at Surgery.

16. The east corridor wall just south of the double doors to Surgery was observed at 2:20 p.m. on March 2, 2010.

a) There are approximately ten penetrations at the top of the smoke barrier wall where the wallboard meets the ceiling support beam.

b) A two foot by three foot piece of wallboard panel was not screwed to the smoke barrier wall and fire taped.

17. The smoke barrier wall in the mens dressing room of the Operating Room (OR) was observed at 2:30 p.m. on March 2, 2010. One penetration for communication wiring conduit was not sealed.

18. The smoke barrier wall in the women's dressing room of the O.R. was observed at 2:35 p.m. on March 2, 2010. The east wall was incomplete to the ceiling cap and there was one penetration of a communication wire through the same wall which was not sealed.

19. The east corridor wall across from Day Surgery was observed at 2:40 p.m. on March 2, 2010. There was one penetration of a three quarter inch conduit which was not sealed above the Day Surgery double doors.

20. The store room behind the Chapel was observed at 3:30 p.m. on March 2, 2010. There were six penetrations of the north wall (all conduits) which were not sealed. The wall where it intersected the ceiling cap was incomplete as the wallboard did not close off the deck flutes.

21. Second floor of the hospital, in the mens dressing room, at the west end of the smoke barrier wall between Surgery and Radiology, was observed at 8:00 a.m. on March 3, 2010. There were two penetrations of the smoke barrier wall where chilled water return and supply pipes were not sealed.

22. The smoke barrier wall between Surgery and Radiology was observed at 8:10 a.m. on March 3, 2010. There were three penetrations of the smoke barrier wall above the ceiling tile. Two of the penetrations were for conduits not sealed and the remaining was for a communication wire not sealed where it went through the wall.

23. The smoke barrier wall which separates Radiology from Surgery was observed at 8:12 a.m. om March 3, 2010.

a) There was one penetration in cubicle #5 where wallboard did not butt up to one another exposing a two inch by six inch hole in the smoke barrier wall.

b) There was one penetration at the lower right hand corner of a large two foot by two foot duct not sealed at cubicle #4 in Radiology.

c) There was one penetration of the smoke barrier wall where a one half inch conduit was not sealed in cubicle #4.

d) There was a pneumatic fire damper hose through the smoke barrier wall above the sitting area in Radiology which was not sealed.

e) There were two penetrations of the smoke barrier wall in Radiology at cubicle #2, both penetrations were for sleeves extending through the wall which were not sealed.

f) In cubicle #1, there was one junction box without a cover which had conduit extending through the smoke barrier wall.

24. The smoke barrier wall between Surgery and Nuclear Medicine was reviewed at 8:35 a.m. on March 3, 2010. There were penetrations of the smoke barrier wall where a return air trunk line extends through the wall of Nuclear Medicine by damper #480.

25. The Specials Computer Room at Radiology was reviewed at 9:30 a.m. on March 3, 2010. There were two penetrations above the ceiling tile near smoke alarm # LO2D86, one was a support wire and the other was a pneumatic tube through the smoke barrier wall which were not sealed.

26. Fire Dampers were observed at 10:20 a.m. on March 3, 2010 on fifth floor north and again on third floor north. The following is a listing of penetrations of the smoke barrier wall which were found on third north:

a) The north wall at the door to the core had a two inch penetration where communication wiring extends through the wall.

b) The east wall at the same location had two penetrations which were not sealed. One was a sleeve which was not sealed and the remaining was a air supply duct which was not sealed at the lower left hand corner.




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27. The smoke barrier above the corridor door that leads to the Credit Union office from the corridor by the first floor conference rooms was examined at 10:32 a.m. on March 2, 2010. There was an open unsealed space around a conduit that penetrates this portion of the smoke barrier.

28. The smoke barrier above the corridor door into the Central Processing suite from the corridor by the first floor elevator lobby was examined at 10:38 a.m. on March 2, 2010. There was an open unsealed space around a 12 inch white pipe and around a drain pipe that penetrate this portion of the smoke barrier. Furthermore, a thermofiber/wool type material had been used a sealant around other penetrations. The Centers for Medicare & Medicaid Services (CMS) does not accept thermofiber/wool material as a sealant in walls that require a fire resistance rating.

29. The smoke barrier above the set of corridor doors into the area that was previously the Bio-med suite on the first floor of the building was examined at 11:00 a.m. on March 2, 2010. There was an open faced conduit being used as a pass through for a white wire that was unsealed. Furthermore, a thermofiber/wool type material had been used a sealant at the meeting edge of the smoke barrier wall and the fluted deck.

30. The smoke barrier above the set of corridor doors into the IT suite from the corridor by the kitchen area on the first floor of the building was examined at 11:08 a.m. on March 2, 2010. There was an open unsealed space around a conduit that penetrates this portion of the smoke barrier. Furthermore, the meeting edges of sheetrock used in the smoke barrier wall were not fire taped/sealed completely.

31. The smoke barrier being the south wall of the IT office suite on the first floor of the building was examined at 11:17 a.m. on March 2, 2010. There was an open faced conduit with open unsealed space around it that penetrates this portion of the smoke barrier. Furthermore, there were two other conduit with open unsealed spaces around them that penetrate this smoke barrier.

32. The smoke barrier above the entry door into the Credit Union office on the first floor of the building was examined at 11:27 a.m. on March 2, 2010. There was a small round open unsealed hole in the smoke barrier.

33. The smoke barrier above the "T" intersection of the corridors by the Credit Union office and the north conference room on the first floor of the building was examined at 11:45 a.m. on March 2, 2010. A thermofiber/wool type material had been used a sealant at the meeting edge of the smoke barrier wall and the fluted deck. Furthermore, the same thermofiber/wool material had been used as a sealant around two white pipes that penetrate this smoke barrier.

34. The smoke barrier above the biohazard waste storage room on the first floor of the building was examined at 11:48 a.m. on March 2, 2010. There was no sealant at the meeting edge of the smoke barrier wall and the fluted deck.

35. The smoke barrier being the west wall of the Central Supply room on the first floor of the building was examined at 11:58 a.m. on March 2, 2010. There were two conduit with open unsealed spaces around them that penetrate this smoke barrier.

36. The smoke barrier above the north office space in what was previously the Bio-med suite on the first floor of the building was examined at 1:33 p.m. on March 2, 2010. There was an open unsealed space around a sprinkler pipe that penetrates this smoke barrier.

37. The smoke barriers above what was once the engineering secretary's office space in the area that was previously the Bio-med suite on the first floor of the building was examined at 1:40 p.m. on March 2, 2010. Both the west and south walls of this space constitute a smoke barrier. The west smoke barrier had no sealant at the meeting edges of the wall with the fluted deck. The south smoke barrier wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.




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38. The fifth floor fire doors were reviewed on March 3, 2010 at 11:17 a.m. On the north side above these doors, a telemetry sleeve was found that had not been sealed on the end.

39. The fourth floor waiting room was reviewed on March 3, 2010 at 11:22 a.m. The smoke barrier wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.

40. The fourth floor fire doors were reviewed at 11:24 a.m. on March 3, 2010. On the south side above these doors. A steel pipe passing through the barrier was not sealed around where it entered the barrier.

41. The fourth floor fire doors was reviewed on March 3, 2010 at 11:22 a.m. The fire barrier wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.

42. The fourth floor smoke barrier was reviewed on March 3, 2010 at 11:31 a.m. at Jani's Office. The barrier wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.

43. The fourth floor barrier wall was reviewed on March 3, 2010 at 11:33 a.m. above the 4 north doors. There were two deficiencies noted:

a) the wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck, and

b) a open ended telemetry sleeve was found that passes through the barrier.

44. The third floor main pipe/utility chase barrier was reviewed on March 2, 2010 at 1:04 p.m. The wall of the chase was incomplete to the fluted deck above.

45. The second floor vertical shafts were reviewed on March 3, 2010 between 8:15 and 8:35 a.m. The following deficiencies were noted:

a) the dumb waiter vertical shaft wall had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck, and

b) the post operation surgery area and the vertical pipe chase that passes through the area had thermofiber/wool type material being used as a sealant at the meeting edge of the wall with the fluted deck.

Based on observations on March 1 - 3, 2010; the facility failed to maintain the fire and smoke resistive rating of smoke/fire barriers.

Findings include:

1. On March 1, 2010 at 11:19 a.m , the first floor boiler room was observed. Fifteen electrical conduits were found that penetrated the east side of the 2 hour barrier between the boiler room and the corridor.

2. On March 1, 2010 at 11:21 a.m., the first floor boiler room south wall was observed. Eight unsealed penetrations were found.

3. The hold open device was reviewed on the second floor west doors of the two hour fire barrier on March 1, 2010 at 12:27 p.m. The metal cover was missing which would not allow the corridor wall to resist the passage of smoke.


4. A carbon steel pipe penetrating the smoke barrier was reviewed above the door 0735 at 11:37 a.m. on March 1, 2010. A gap existed around the pipe as it entered the smoke barrier above the smoke barrier doors.

5. The south smoke barrier doors on the first floor were observed on March 1, 2010 at 12:03 p.m. The hold open device cover was missing allowing no resistance to the passage of smoke to the corridor walls.

6. The hold open device was reviewed on the north doors (labeled as 0735) of the smoke barrier on first floor on March 1, 2010 at 11:33 a.m. The metal cover was missing which would not allow the corridor wall to resist the passage of smoke.

7. The two hour fire barrier was observed near the second floor elevator lobby on March 1, 2010 at 1:31 p.m. Three penetrations were found above the doors as follows:

a) a one inch hole passed through the barrier where electrical conduit or piping had been removed,

b) two electrical conduits penetrated the fire barrier and need to be sealed between the sheet rock and the conduit.

8. The two hour fire barrier in the second floor consult area contained was reviewed on March 1, 2010. Two penetrations were found through the two hour barrier.

a) a four inch fire protection pipe penetrated the wall and was not sealed between the wall and the pipe, and

b) an inch and one half fire protection pipe was not sealed between the wall and the pipe.

9. On the second floor above the smoke barrier doors labeled 0884, the wall was reviewed on March 1, 2010 at 2:13 p.m. The wall contained two unsealed penetrations:

a) one wire, and

b) one electrical conduit.

10. The second floor smoke barrier was reviewed on March 1, 2010 at 2:16 p.m. The following deficiencies were found:

a) two unsealed holes were found through the smoke barrier wall above the lay in ceiling, and

b) the fire protection wiring that ran through a sleeve was not sealed on the end.

11. At 2: 19 p.m. on March 1, 2010, the service elevator smoke curtain in the two hour fire barrier was observed. Two penetrations existed in the barrier as follows:

a) an unsealed penetration existed around the mechanism for the rolling smoke curtain, and

b) a pipe that is unsealed as it enters the 2 hour barrier.

12. The generator room was reviewed on March 1, 2010 at 2:30 p.m. A penetration through the two hour fire barrier was found related to a leak in a pipe and around a three quarter inch copper pipe. The area around the pipe was in need of repair or sealing by an approved fire stopping material.

13. The second floor smoke barrier near door 0767 was reviewed at 2:51 p.m. on March 1, 2010. The smoke barrier contained an electrical conduit that passed through it that was unsealed as it entered the barrier.

14. The second floor smoke barrier wall separating the ambulatory surgical center and the hospital was reviewed on March 1, 2010 at 3:07 p.m. A open ended sleeve passed through the east to west barrier with no wires in it. The sleeve passed through the corner of the wall as the wall changed directions to the north 90 degrees.

15. The second floor smoke barrier wall inside the security office was reviewed on March 1, 2010 at 3:22 p.m. Two water pipes entered the smoke barrier were not sealed completely. The valves on these water lines were labeled as 149 and 150.

16. The third floor day area smoke barrier was reviewed on March 1, 2010 at 3:31 p.m. An electrical conduit was found unsealed as it entered the barrier above the television.

17. The third floor smoke barrier was reviewed on March 1, 2010 at 3:36 p.m. A patch was made on the smoke barrier without the proper application of sealant on the patch. The wall contained a one inch by one and one half inch cutout that had not been sealed around after being replaced.

18. The third floor smoke barrier was reviewed on March 1, 2010 at 3:36 p.m. A hole was left in the smoke barrier where a conduit had been removed.

19. The third floor smoke barrier above the public rest room and quiet room was reviewed on March 1, 2010 at 3:48 p.m. Seven conduits passed through the barrier with thermo fiber/mineral wool around them. There were gaps around the thermo fiber/mineral wool. The same material was used to seal the wall to the fluted ceiling pan above. This material is not an acceptable smoke sealant as directed by CMS.

20. The fourth floor smoke barrier was reviewed on March 2, 2010 at 8:47 a.m. The smoke barrier hold open device, flexible electrical conduit was not properly sealed as it entered the smoke barrier above doors labeled as 0857.

21. The second floor telecommunication room was reviewed on March 2, 2010 at 10:50 a.m. The room contained at least 24 conduits with blue, brown, and white wires going into conduits for various rooms on the floor. These conduit need to be sealed to prevent the passage of smoke from one smoke compartment to the other.

Based on observation, the facility failed to install fire doors on all hazardous areas (including boiler rooms and storage rooms).

NFPA 101 Section 39.3.2.1 Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.


NFPA 101 Section 8.4.1.1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

NFPA 101 Section 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Findings include:

The main floor telecommunications room was observed at 2:05 p.m. on March 3, 2010. There was no self-closing device on the door to this hazardous room.

Based on observations made on March 1-3, 2010, the facility failed to maintain or establish the fire rated protection for a hazardous area.

The findings include:

1. The fire rated door to the General and Gynecology store room was not self-closing as observed at 1:55 p.m. on March 1, 2010. There was no self-closing devise on the door to the store room.

2. The janitors closet door at Day Surgery was observed for proper closing and latching at 3:10 p.m. on March 2, 2010. There was no self-closing devise on the store room door.

Based on observations made on March 1 - 2, 2010; the facility failed to maintain the proper door rating, allow doors with self closures from being blocked open, or to maintain the self closures for hazardous areas.

Findings include:

1. The fire rating of the engineering office door was observed on March 1, 2010. The door, labeled as 0700, is part of the one hour barrier separating the boiler room from the corridor. The door was rated at 20 minutes and should have been rated at least at 45 minutes.


2. The fire rating of the boiler room door was observed on March 1, 2010. The door, labeled as 0701, is part of the one hour barrier separating the boiler room from the corridor. The door was rated at 20 minutes.

3. Room 109 P4 was reviewed on March 1, 2010 at 12:00 p.m. The door with a self closure device was held open with a garbage can. The garbage can was removed by maintenance staff when the deficiency was discovered. The room was used as storage.

4. Room 108 was reviewed on March 1, 2010 at 12:02 p.m. The room contained storage of combustible materials. The door self closer was installed, but was disconnected.

5. On the second floor in the "Adolescent Outpatient" area, a storage room labeled with a "No Exit" sign, did not have a self closure device. The door was labeled as door 0781.

6. The second floor ambulatory surgical suite was reviewed on March 2, 2010 at 11:30 a.m. Three storage room doors in the sterile corridor were lacking a self closure mechanism.

a) door 0900 had the self closure removed,

b) door 0891 had the self closure disconnected, and

c) door 890 lacked a self closure as well.

Based on observations on March 1 - 3, 2010; the exit enclosures for two stairways were not properly rated.

Findings include:

1. The first floor stairway enclosure at the southeast stairway near the housekeeping department serves as the ground level means of egress for five stories. The door protecting this stairway shall be at least a one and one-half hour rated door. There was no label on the door protecting this stairway to attest to its fire rating as observed at 2:08 p.m. on March 1, 2010.

2. The north stairway that serves as an exit from the seventh floor Life Flight office area was being used for storage purposes as observed at 9:52 a.m. on March 2, 2010. A red tarp was found to be draped over the handrail system of the stairway at this level.

Based on observation, the facility failed to protect all vertical openings in stairways with fire rated doors with automatic self-closing devices.

NFPA 101 Section 39.2.2.3.1 Stairs complying with 7.2.2 shall be permitted.

NFPA 101 Section 7.2.2.5.1 Enclosures. All inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2. All other inside stairs shall be protected in accordance with 8.2.5.

NFPA 101 Section 7.1.3.2.1(c) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8.

Findings include:

1. The stairway to the north west mechanical room was observed at 1:30 p.m. on March 3, 2010.
a) The door at the bottom of the stairway was not a solid core door and was not self closing.
b)The door into the mechanical room at the penthouse level was also not self-closing.

2. The partial basement which was used to store medical records was observed at 2:00 p.m. on March 3, 2010.
a) The door at the main level had a louver in the door and was not self-closing.
b) There was no self closing door at the basement level separating the two levels.

Based on observations on March 1, 2010; the facility failed to complete two hour construction for the east stairwell at the second level.

According to Section 7.1.3.2.1 of NFPA 101, where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) * The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.

Finding include:

The second floor west stairwell wall construction was reviewed on March 1, 2010 at 1:38 p.m. The east side of the stairwell wall was incomplete as two hour construction. Metal studs were seen on the outside of the stairwell which is not a complete two hour separation per Section 7.1.3.2.1 of NFPA 101.

Based on observations made in the facility on March 3, 2010; the facility stored materials in stair landings which are part of the egress.

In accordance with 7.1.3.2.3 and 7.2.2.5.3 of NFPA 101, an exit enclosure, including an exit stairway, shall not have any open space within the enclosure used for any purpose (storage) that has the potential to interfere with egress.

Findings include:
The second story landing near the loading dock was observed at 11:55 a.m. on March 3, 2010. The landing area contained carts used for holding meal containers used for transporting meals to other areas much like "Meals on Wheels". Storage of items in a stair enclosure is not allowed under Section

Based on observation, the facility failed to maintain exits free of all obstructions.

NFPA 101 Chapter 39 Existing Business Occupancies 39.2.1.1 All means of egress shall be in accordance with Chapter 7 and this chapter.

NFPA 101 Chapter 7 Means of Egress, Section 7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

NFPA 101 Chapter 7 Means of Egress, Section 7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.


Findings include:

1. The south exit from Physical Therapy (PT) was observed at 11:00 a.m. on March 1, 2010. The exit was blocked by beverage canisters and a clear path was not being maintained as required.

2. The south exit from PT to the public way was observed at 11:05 a.m. on March 1, 2010. The sidewalk was not finished to the public way as it ended approximately three feet outside the building. There was approximately thirty five feet of grass to another sidewalk out near the street.

Based on observations on March 1 - 3, 2010; the facility failed to assure that a corrdior door was capable of being opened with minimal force applied.

The forces required to fully open any door manually in a means of egress shall not exceed 15 pounds of force to release the latch, 30 pounds of force to set the door in motion and 15 pounds of force to open the door to the minimum required width per Section 7.2.1.4.5 of NFPA 101. These forces shall be applied at the latch stile.

Findings include:

The second floor set of doors labeled 0764 were exercised on March 1, 2010. The panic hardware was pushed after the doors were tested for closurer. The panic bar would not realase the latching mechanism without more than 15 pounds of force.

Based on observation, the facility failed to ensure that all exit discharges were provided with illumination.


According to Section 7.9.2.1 of NFPA 101, emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6 lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

Findings include:

The south exit discharge from the second floor was reviewed on March 2, 2010 at approximately 10:00 a.m. There was no external lighting at the exit.

Based on observations made on March 1, 2010 the facility failed to maintain an exit sign to assure that when fully illuminated the letters could be plainly read.

The findings include:

An exit sign located on the south wall of the southeast portion of the Laboratory suite on the first floor showed signs of heat having affected the transparency of the material used for the letters as observed at 12:50 p.m. on March 1, 2010. The heat had darkened the material to the point where the lights behind the letters were no longer capable of illuminating them for visual purposes. Note: The placard material used for the letters on the sign was replaced after the observation was made and confirmed by the surveyor on-site.

Based on observation, the facility failed to maintain all exit signs in accordance with Section 39.2.10 of NFPA 101.

NFPA 101 Section 7.10.1.2 Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

NFPA 101 Section 7.10.5.1General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings include:

1. The exit signs were observed for illumination at 1:45 p.m. on March 3, 2010. The exit sign in X-Ray out of Suite J was not illuminated as required.

2. The exit sign in Suite H was not illuminated as observed at 1:50 p.m. on March 3, 2010.

Based on observations on March 1, 2010; the facility failed to install approved exit signage per Section 7.10.1.2 of NFPA 101.

In accordance with 7.10.1.2 of NFPA 101, exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Findings include:

The west exit from the kitchen to the corridor includes an illuminated exit sign with both of the Chevrons-Type indicators illuminated as well. The chevrons should not be removed as to avoid confusion for facility staff in an emergency. The egress is directly through the door the exit sign is above as noted on March 1, 2010 at 12:50 p.m.

Based on observations made on March 1, 2010, the facility failed to assure that a manual pull station for the fire alarm system was accessible.

The findings include:

Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible per 2-8.2.1 of NFPA 72, 1999 edition. The manual pull station located along the east wall of the kitchen area on the first floor was obstructed by the placement of carts in front of it as observed at 3:35 p.m. on March 1, 2010.

Based on observation and interview, the facility failed to maintain the fire alarm system in accordance with NFPA 72, 1999 Edition, and provide records of maintenance and service.

Findings include
NFPA 101 Section 4.6.12.2 Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

1. The fire alarm system was reviewed at 1:45 p.m. on March 3, 2010. The Fire Alarm Control Panel (FACP) was located in the northeast penthouse. The alarm panel did not identify which electrical panel supplied power for the alarm, nor was the electrical panel identified in red for the breaker which supplied power to the FACP.

A fire alarm system is not required in a Class B occupancy, but when they are installed they must be maintained as required by NFPA 101 Section 4.6.12.

2. There was no notification device (sounding device/bell) at the north east entry to the building as observed at 2:25 p.m. on March 3, 2010.

3. The FACP was observed to be in a non continuously occupied area of the northeast penthouse. A smoke/heat detector was not observed within five feet of the FACP and interconnected to the fire alarm panel.

Based on interview, the facility failed to test all smoke/heat detectors in accordance with NFPA 72.

Findings include:

1. A partial fire alarm system was in the Garden City Medical Arts Building as observed at 1:30 p.m. on March 3, 2010. When asked if the fire alarm system had received inspections, testing and maintenance since occupying the building, the maintenance staff replied that no testing of the alarm system had occurred since it was occupied.

2. The main fire alarm control panel was installed in the north east penthouse. Heat and duct detectors were installed in the building as part of the fire alarm system. Smoke and heat detectors installed as part of a fire alarm system, whether required or not, shall be maintained and tested in accordance with NFPA 72. There was no record indicating that the fire alarm system had received inspection, testing or maintenance since the building was occupied. There was no record of sensitivity testing on any heat and duct detectors since the building was occupied.

Based on observations on March 3, 2010; the facility failed to ensure that the circuit breaker controlling the fire alarm control panel (FACP) had a red marking in the designated panel identifying the fire alarm panel.

In accordance with Section 1-5.2.5.2 of NFPA 72 ,1999 edition, the connections to the light and power service for FACP shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Findings include:

On March 3, 2010 12:05 p.m., the FACP in the engineering office was examined. The FACP was labeled with the appropriate information for the circuit breaker and electrical panel that controlled the FACP as "AC Power LL- 12". When the electrical panel was reviewed, breaker #12 was not marked in red.

Based on observations and interview with maintenance staff on March 1-3, 2010, the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system.

The findings include:

In accordance with section 5-13.8.1 of NFPA 13, 1999 edition; sprinklers shall be installed under exterior roofs or combustible canopies exceeding 4 feet in width. The building is of Type I (332) construction which requires that it be protected throughout by an approved automatic sprinkler system.

1. The access space to the top of the dumb waiter shaft was observed at 8:50 a.m. on March 2, 2010. The access space measured approximately twelve feet by twenty feet and was not protected by the facility sprinkler system.



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2. The area previously used for the Bio-med department on the first floor of the building was in the process of being remodeled at the time of the survey. Two existing closets on the west side of this area did not have sprinkler protection within their confined spaces as observed at 10:52 a.m. on March 1, 2010.

3. A mechanical room was accessed through the locker room for the Laboratory personnel on the first floor of the building. The mechanical room had ductwork that exceeded four feet in width and in accordance with 5-5.5.3.1 of NFPA 13, 1999 edition sprinklers shall be installed under fixed obstructions over four feet wide such as ducts, decks, open grate flooring cutting tables, and overhead doors. Under one of the ducts that exceeds four feet in width was stored cardboard boxes, filters and foam mattresses. There was no sprinkler located under this ductwork to provide coverage for these stored items or the general area as observed at 1:10 p.m. on March 1, 2010.

4. An elevator mechanical room was accessed from the Central Processing suite on the first floor of the building. The elevator mechanical room was located on a level lower than that of the Central Processing suite and accessed by means of stairs. There was no sprinkler protection provided in the lower level area of the elevator mechanical room as observed at 3:12 p.m. on March 1, 2010.

5. The room housing the transfer switches for the emergency generators was located in a two-hour fire rated enclosure/room located off of the chiller room on the first floor of the building. The room was not protected by the sprinkler system as observed at 1:00 p.m. on March 2, 2010.

Based on observations on March 2, 2010; the facility failed to sprinkler all portions of the building.

NFPA 101 Section 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

Findings include:

The third floor "Adolescent Storage" room lacked a sprinkler head in the space. The space appeared to have changed overtime related to a medicine distribution office created on the other side of this room. This construction may have excluded the sprinkler protection for this area.

Based on observations made on March 2, 2010, the facility failed to provide for electronic supervision of sprinkler control valves.

The findings include:

The water pipe for supplying water to the fire pump and riser system originating from the fire pump was examined at 1:15 p.m. on March 2, 2010. The water supply pipe located on the first floor of the chiller room had two control valves, one on each side of the backflow device. These two control valves were provided with chains and locks as a means of securing them in the open position. There were no tamper switches attached to these two control valves to provide for electronic supervision and alarm notification of the valves when closed.

Based on review of the fire sprinkler service and testing reports on March 1-3, 2010, the facility failed to assure that the sprinkler system is maintained in accordance with the standards of NFPA 13 and NFPA 25. The facility also failed to keep the sprinkler pattern coverage free and unobstructed

The findings include:

1. The fire sprinkler service and testing reports were reviewed between 4:30 and 5:30 p.m. at the facility on March 1, 2010. There was no information in the reports which listed the static pressure or the residual pressure for the installed sprinkler system. There was evidence that all necessary monthly and quarterly reports had been done on a timely basis, but not all the required information was in the reports.



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2. The locker room for the Laboratory personnel on the first floor of the building was examined at 1:10 p.m. on March 1, 2010. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane below the sprinkler deflector or the top of storage shall be maintained with a minimum of 18 inches clearance per 5-5.5.3 and 5-5.6 of NFPA 13, 1999 edition. The majority of lockers in this room had a slanted top to prevent the storage of items on top of the lockers. The lockers which protrude from the wall into the center of the room had flat tops and personal items were stored on top of the lockers. The items were within 18 inches of the sprinkler head in this location and obstructed the coverage pattern of that sprinkler.

3. The sprinkler service and inspection reports for the building were reviewed between 4:30 and 5:30 p.m. on March 1, 2010. An anti-freeze loop was installed and the valve and testing piping for that system was located in a room adjacent to the power lift assembly in the first floor maintenance area suite. The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary per 2-3.4 of NFPA 25, 1998 edition. The antifreeze solution shall be prepared with a freezing point below the expected minimum temperature for the locality per 4-5.2.3 of NFPA 13, 1999 edition. There was no documentation found that noted the gravity (rating) of the anti-freeze in that loop to assure that it was of sufficient strength to prevent freezing.

4. The penthouse housing the elevator mechanical room accessed from a stairway by the seventh floor Life Flight helicopter offices was examined at 9:50 a.m. on March 2, 2010. Sprinkler piping or hangers shall not be used to support nonsystem components per 6-1.1.5 of NFPA 13. 1999 edition. Grounding wires were found to be attached to the sprinkler piping in this room.

Based on observations made from March 1 - 3, 2010; the facility failed to maintain the sprinkler system components in accordance with the standards of NFPA 13 and NFPA 25.

In accordance with Section 2-2.1.1 of NFPA 25, 1998, sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.


Findings include:

1. An escutcheon ring was found to be missing in Room 104 on March 1, 2010.

2. On March 1, 2010 at 12:29 p.m. inside the first floor mens bathroom, an escutcheon ring was found to be missing on a sprinkler head located near a florescent light.

3. An escutcheon ring was found missing inside the first floor elevator mechanical room at 12:43 p.m. on March 1, 2010.

4. An escutcheon ring was found missing inside room 368, elevator mechanical or telecommunication room. This third floor room was reviewed at 3:56 p.m. on March 1, 2010.

5. The fire sprinkler service and testing reports were reviewed between 4:30 and 5:30 p.m. at the facility on March 1, 2010. There was no information in the reports which listed the static pressure or the residual pressure for the installed sprinkler system. There was evidence that all necessary monthly and quarterly reports had been done on a timely basis, but not all the required information was in the reports.

6. On March 2, 2010 at 9:10 a.m. in the fourth floor "Gym", an escutcheon ring was found to be missing.

7. On March 2, 2010 at 10:31 a.m. the staff area in Outpatient area was reviewed. An escutcheon ring was missing for a sprinkler head in the room.

8. On March 3, 2010 at 11:50 a.m., the doctors entrance to the ambulatory surgical center was lacking an escutcheon ring.

Based on observation, the facility failed to maintain all portable fire extinguishers in accordance with NFPA 10.

NFPA 101 Section 39.3.5 Extinguishment Requirements. Portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. (See also Section 39.4.)

NFPA 101 Section 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Findings include:

A portable fire extinguisher located in the northeast penthouse was observed for proper maintenance at 1:45 p.m. on March 3, 2010. The fire extinguisher had been placed in service in 1995 and carried a identification of GCMP#1. The next hydo test was in 2008, thirteen years after being placed in service. There was no tag identifying that the extinguisher had received a six year maintenance test, in 2001 or the twelve year hydro test required in 2007.

Based on observations made on March 1-3, 2010, the facility failed to assure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

The findings include:

Fire extinguishers shall be hydrostatically retested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

1. The second floor Kitchen penthouse was observed at 10:05 a.m. on March 1, 2010. The portable fire extinguisher was not hung as required, but was resting on the penthouse floor. The same fire extinguisher had not been serviced annually since 1999.

2. The second floor Day Surgery penthouse was observed at 10:20 a.m. on March 1, 2010. There was no portable fire extinguisher in the Day Surgery penthouse as required.

3. The electrical room of Emergency Room (ER) was observed at 12:50 a.m. on March 1, 2010. The portable fire extinguisher in the electrical room was not mounted to the wall and had not been serviced annually since September of 2008.

4. The dry chemical portable fire extinguisher located in the corridor of Operating Room (OR) was examined at 2:05 p.m. on March 1, 2010. The label attached to the extinguisher noted that it had received a six year inspection in 1996. The extinguisher was due for its hydrostatic test in 2002. The extinguisher did not receive a hydrostatic test or the second six year maintenance test until 2004. There was no collar on the extinguisher to distinguish that the cylinder had been emptied and recharged.

5. A dry chemical portable fire extinguisher located in the International Heart Institute (IHI) waiting room was examined at 3:02 p.m. on March 1, 2010. The extinguisher received a six year maintenance in 2000, and was to receive a second six year maintenance in 2006, but it did not get done until 2007. The extinguishers sticker did not indicate that it had been hydrotested after twelve years and it did not have a collar indicated that it had either.


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6. The dry chemical portable fire extinguisher located in the area that was previously the Bio-med room on the first floor was examined at 11:00 a.m. on March 1, 2010. The extinguisher was manufactured in 1987. The only testing label attached to the extinguisher noted that a six-year test was done in 2007. There was no documentation as to when the last twelve-year hydrotest (due in 1999) was performed on the cylinder.

7. The dry chemical portable fire extinguisher located in the corridor by Conference room A on the first floor was examined at 8:45 a.m. on March 2, 2010. The extinguisher was manufactured in 1996. The only testing label attached to the extinguisher noted that a six-year test was done in 2007. There was no documentation as to when the last twelve-year hydrotest (due in 2008) was performed on the cylinder. Nor was there a label attesting that the initial six-year test had been performed in 2002.

8. The dry chemical portable fire extinguisher located across from the staff break room in the Laboratory suite on the first floor was examined at 8:50 a.m. on March 2, 2010. The extinguisher was manufactured in 2001. The only testing label attached to the extinguisher noted that a six-year test was done in 2008. This test should have been performed in 2007 to conform to the six-year period required.

9. The dry chemical portable fire extinguisher located in the penthouse housing the elevator mechanical room accessed from a stairway by the seventh floor Life Flight helicopter offices was examined at 9:50 a.m. on March 2, 2010. The extinguisher was manufactured in 1982. Two testing labels were attached to the extinguisher noting that a six-year test was done in 1995 and that a combination six-year and twelve-year hydrotest were done in 2008. There was a gap in documentation between the six-year test in 1995 and the next required test (hydrotest due in 2001). According to the labels attached, the extinguisher went a period of thirteen years between the next required testing dates.

10. The dry chemical portable fire extinguisher located in the corridor across from the Credit Union office on the first floor was examined at 11:31 a.m. on March 2, 2010. The extinguisher was manufactured in 1984. Two testing labels were attached to the extinguisher noting that a six-year test was done in 1996 and that a twelve-year hydrotest were done in 2005. There was a gap in documentation between the six-year test in 1996 and the next required test (hydrotest due in 2002). According to the labels attached the extinguisher went a period of nine years between the next required testing dates.

Based on observations on March 1-3, 2010, the facility failed to assure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10.

Fire extinguishers shall be hydrostatically retested per 5-2 of NFPA 10, 1998 edition, at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

Findings include:

The extinguishers throughout the building were missing proof of the 6 year test as required per Table 5-2 of NFPA 10.

Based on observations made on March 1 - 3, 2010; the facility failed to maintain adequate means of egress. The means of egress from the storage area in the basement area was reduced in size by storage of kitchen related items.

According to Section 7.1.10.1 of NFPA 101; means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings include:

1. The first floor, north kitchen storage area was reviewed at 11:41 a.m. on March 1, 2010. Two deficiencies were noted:

a) Several kitchen related items; food warmers, metal racks, plastic garbage bins, etc., were stored in the exit reducing width of egress.

b) The gate on the west side of the elevator door in the storage room was locked with a keyed lock.

2. During the fourth floor fire drill on March 3, 2010 at approximately 11:00 a.m., a handwashing stand was noted as being in the corridor as the fire drill occurred. This item will have to be located in an area where it will not reduce the width of the corridor or hung on the wall.

3. On the third floor on March 3, 2010 at approximately 11:30 a.m., a fire drill was performed. Four chairs were noted to be in the corridor and were used for new patients as they are admitted as indicated by staff. These chairs need to moved out of the egress corridor to a location that does not reduce the width of the corridor.

Based on observations made on March 2, 2010; the facility failed to provide documentation or proof that draperies, cubicle curtains, etc. were fire retardant as required.

According to Section 10.3.1 of NFPA 101; where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Findings include:

1. The fourth floor "gym" was reviewed on March 2, 2010 at 9:10 a.m. Two curtains used to separate space were found to not be labeled to indicate they meet NFPA 701 as being flame resistant. When asked, the maintenance staff could not provide documentation that these curtains meet NFPA 701.

2. The second floor counselors file room 2 was observed on March 2, 2010. There were no tags indicating the flame resistance of two curtains hung in the room. When asked the maintenance staff could not provide documentation that they meet NFPA 701.

3. The second floor mission leadership office was reviewed. There were no tags indicating the flame resistance of curtains hung in the room. When asked the maintenance staff could not provide documentation that they meet NFPA 701.

4. The second floor ambulatory surgical suite was reviewed on March 2, 2010 at 11:03 a.m. Two curtains were found in the suite that were not tagged indicating their flame resistance. When asked the maintenance staff could not provide documentation that they meet NFPA 701.

Based on observations made on March 1, 2010, the facility failed to maintain the medical gas or compressed gas systems and cylinder storage areas in conformance with the standards of NFPA 99, 1999 edition.

The findings include:

1. The medical gas manifold and storage room was located off of the loading dock on the south end of the first floor of the building. Freestanding or unsecured cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down per 8-3.1.11.2(h) and 4-3.5.2.1(b27) of NFPA 99. An "E" size cylinder of oxygen was observed to be unsecured and lying on the floor surface of this room at 2:10 p.m. on March 1, 2010.

2. The medical gas manifold and storage room was located off of the loading dock on the south end of the first floor of the building. In any storage location housing nonflammable gases the electric wall fixtures, switches, and receptacles in that enclosure shall be installed in fixed locations not less than 5 feet above the floor as a precaution against their physical damage per 4-3.1.1.2(a)4 of NFPA 99. The light switch in this room was measured and found to be four feet from the floor surface as observed at 2:10 p.m. on March 1, 2010.

3. A hazardous materials room containing other pressurized gases was adjacent to the medical gas manifold and storage room located off of the loading dock on the south end of the first floor of the building. This room was separated by one-hour construction from other portions of the building. Storage of flammable and nonflammable gases in cylinders shall comply with 4-3.1.1.1 and 10-10.2.1 of NFPA 99. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. A free-standing cylinder of Ethanol (flammable gas) and a free-standing cylinder of Carbon Dioxide (nonflammable gas) were observed at 2:15 p.m. on March 1, 2010 in this room.

Based on observations made on March 1, 2010, the facility failed to maintain the medical gas or compressed gas systems and cylinder storage areas in conformance with the standards of NFPA 99, 1999 edition.

In any storage location housing nonflammable gases, the electric wall fixtures, switches, and receptacles in that enclosure shall be installed in fixed locations not less than 5 feet above the floor as a precaution against their physical damage per 4-3.1.1.2(a)4 of NFPA 99.

Findings include:

The medical gas manifold and storage room is located off of the loading dock on the north east corner of the building of the second floor. The light switch in this room was observed at 12:10 p.m. on March 1, 2010 and was not at five feet.

Based on observations made on March 3, 2010, the facility failed to assure that a cylinder of oxygen was properly secured from falling over or being knocked down. In addition, three R-22 refrigerant tanks were stored in a mechancial room.

Freestanding cylinders of nonflammable gases such as oxygen, shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down (Section 8-
3.1.11.2(h) and 4-3.5.2.1(b) of NFPA 99, 1999 edition).

The findings include:

1. An "E" size cylinder of oxygen was found to be freestanding at the bottom of the stairway which leads to a roof top store room as observed at 1:00 p.m. on March 3, 2010.

2. Three R-22 refrigerant cylinders were located in the northwest mechanical penthouse as observed at 1:45 p.m. on March 3, 2010. R-22 refrigerant gas is combustible by nature and should not be stored in the penthouse space.

Based on observation, the facility failed to maintain electrical wiring and equipment in accordance with NFPA 70.

Extension cords, including power strips or multiple adaptors, used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction. One means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, 1999 edition and 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99, 1999 edition. The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle and not connected in series or "daisy chained".

NFPA 70, Article 110-26 states that ufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches, whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26. Working space required by this Article shall not be used for storage.

NFPA 70, Article 384-13 requires that all panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors. NFPA 70, Article 110-22. Identification of Disconnecting Means states that each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

Findings include:

1. An orange extension cord was found in use in the northeast penthouse as observed at 1:20 p.m. on March 3, 2010.

2. There were two multi-plug adaptors found in use in the northeast penthouse as observed at 1:21 p.m. on March 3, 2010.

3. There were two surge protected cords found in series (plugged one into the other) in the northeast penthouse.

3. A brown extension cord was in use for a ceiling light in the northwest penthouse as observed at 1:45 p.m. on March 3, 2010.

4. Two extension cords were found in use along the east wall of the telecommunications room as observed at 1:50 p.m. on March 3, 2010.

5. Stored items were located in front of the electrical panels of the telecommunications room as observed at 1:51 p.m. on March 3, 2010.

6. Stored items were located in front of the main electrical panel in the basement as observed at 2:00 p.m. on March 3, 2010.

Based on observations made on March 1-3, 2010, the facility failed to maintain the electrical system or its components in accordance with the standards of NFPA 70, NFPA 99 and/or CMS interpretations.

The findings include:

Extension cords including power strips or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction. One means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, 1999 edition; 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99, 1999 edition; and interpretations from th Centers for Medicare and Medicaid. (CMS). The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle. No overcurrent device shall be connected in series or "daisy chained" with any conductor that is intentionally grounded per Article 240-22 of NFPA 70, 1999 edition.

1. The gift shop electrical system was observed at 11:50 a.m. on March 1, 2010. One extension cord was found in use in place of permanent wiring.

2. The Tissue Engineering Lab in the International Heart Institute was reviewed for electrical problems at 2:55 p.m. on March 1, 2010. An extension cord was found in use in place of permanent wiring.

3. The elevator mechanical room on the sixth floor behind the sleeping quarters for the heliport personnel was observed at 9:35 a.m. on March 2, 2010. There were two orange extension cords in use in place of permanent wiring.



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4. The electrical room housing the anti-freeze sprinkler control piping within the engineering suite on the first floor was examined at 10:30 a.m. on March 1, 2010. Two machines for cleaning out pipes were parked directly in front of panel boards IRE2 and IRE3. The width of the working space in front of electrical equipment shall be the width of the equipment or 30 inches, whichever is greater per 110-26 of NFPA 70, 1999 edition. The work space shall permit at least a 90 degree opening of equipment doors or hinged panels and shall not be used for storage. The two machines parked in front of the panel boards infringed on the work space required for access to that electrical equipment.

5. The bathroom located in the previous Bio-med suite on the first floor was examined at 10:54 a.m. on March 1, 2010. The GFCI receptacle in this room was tested by both means of its self testing buttons and an independent testing instrument. When tested the GFCI receptacle failed to reset. Note: The GFCI receptacle was replaced with a new one after the observation was made and confirmed by the surveyor while on-site.

6. A mechanical room was accessed through the locker room for the Laboratory personnel on the first floor of the building. Numerous items and boxes were parked or stored directly in front of panel board 1EPE and four other master switches/breakers on a north wall of this room as observed at 1:06 p.m. on March 1, 2010. These items infringed on the work space required for access to that electrical equipment

7. The bathroom located in the Central Processing suite on the first floor was examined at 3:05 p.m. on March 1, 2010. The GFCI receptacle in this room was tested by both means of its self testing buttons and an independent testing instrument. When tested the GFCI receptacle failed to reset.


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8. The fifth floor fire barrier was reviewed on March 2, 2010 at 11:17 a.m. Above the doors, a junction box was found that was missing a cover.

Based on observations made from March 1 to 3, 2010; the facility failed to meet the requirements of NFPA 70, National Electrical Code, 1999 edition.

In accordance with Article 110-26 of NFPA 70; sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches, whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26. Working space required by this Article shall not be used for storage.

According to Article 384-13 of NFPA 70; all panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors. NFPA 70, Article 110-22. Identification of Disconnecting Means states that each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

According to Article 517-20 of NFPA 70; all receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption of power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.

Findings include:

1. On the second floor in the telecommunication room, an electrical junction box was found to not have a cover in place. The cover was in the same area and was replaced by the maintenance staff at the time of survey.

2. On the second floor in the generator room, the electrical panel schedule for "Panel 1E" was reviewed at 2:31 p.m. The panel was not current as breakers were on with no indication what they were for on the panel schedule.

3. On the second floor in the generator room, the electrical panel schedule for "Panel ID" was reviewed at 2:31 p.m. on March 2, 2010. The panel was not current as breakers were on with no indication what they were for on the panel schedule.

4. The third floor patient laundry area used for rehabilitation purposes, did not include a ground fault circuit interrupter (GFCI) for an outlet near the sink. The outlet and cover plate were red in color.

5. On the fourth floor in electrical panel labeled "Panel 3A" some circuits in the panel were on but there was no label for what they controlled. This observation was made on March 2, 2010 at 9:20 a.m.

6. The first floor storage area was reviewed on March 3, 2010 at 9:55 a.m. Several items were stored in front of the electrical panel in the storage area including a two portable fans, an infectious waste stand, a plant, and a cardboard box.

7. On the second floor in room 206 there were two electrical panels with panel schedule needing to be updated. The panels were labeled as "Panel 1A and 1B".

8. On the second floor in room 206, there were items stored in front of the electrical panels. Items included a rocking chair and hospital bed rolling tray.

9. On the second floor in the Adolescent Out Patient area, there were two panels in need of updates to the panel schedules. The panels were labeled as panel 1LH and 1CH.

10. Room 205 on the second floor was reviewed on March 2, 2010 at 10:47 a.m. The room contains a sink that has an electrical outlet within near the sink. The electrical outlet lacked the proper GFCI protection.

Based on review of the fire plan on March 3, 2010; the facility failed to have a fire watch policy which included that the authority having jurisdiction (State Agency) shall be contacted whenever it was instituted.

In accordance with Section 9.7.6.1 of NFPA 101; where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the fire plan was provided to the survey team and was reviewed at 7:30 a.m. on March 3, 2010. The fire watch policy addressed the procedures to be followed whenever the automatic sprinkler system was out of service for more than 4 hours in a 24-hour period. However, the fire watch policy did not specifically include notification of the State Agency at 406-444-4170 whenever the sprinkler system was out of service for longer than 4 hours in 24 hour period

Based on review of the fire plan, the facility failed to have a fire watch policy which included that the authority having jurisdiction (State Agency) shall be contacted whenever it was instituted.

In accordance with the Section 9.7.6.1of NFPA 101 of the 2000 Edition; where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the fire plan was provided to the survey team and was reviewed at 7:30 a.m. on March 3, 2010. The fire watch policy addressed the procedures to be followed whenever the automatic sprinkler system was out of service for more than 4 hours in a 24-hour period. However, the fire watch policy did not specifically include notification of the State Agency at 406-444-4170 whenever the sprinkler system was out of service for longer than 4 hours in 24 hour period

Based on review of the fire plan on March 3, 2010; the facility failed to have a fire watch policy which included that the authority having jurisdiction (State Agency) shall be contacted whenever it was instituted.

In accordance with Section 9.6.1.8 of NFPA 101; where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the fire plan was provided to the survey team at 7:30 a.m. on March 3, 2010. The fire plan did have a fire watch policy that addressed the procedures to be followed whenever the fire alarm system was out of service. The policy did not specifically include notification of the State Agency at 406-444-4170 whenever the fire alarm system was out of service for more than 4 hours in a 24 hour period.

Based on review of the fire plan, the facility failed to have a fire watch policy which included that the authority having jurisdiction (State Agency) shall be contacted whenever it was instituted.

In accordance with Section 9.6.1.8 of NFPA 101, 2000 Edition, where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authorities having jurisdiction shall be immediately notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Upon the system(s) being returned to service, the authorities having jurisdiction shall also be notified.

Findings include:

A copy of the fire plan was provided to the survey team at 7:30 a.m. on March 3, 2010. The fire plan did have a fire watch policy that addressed the procedures to be followed whenever the fire alarm system was out of service. The policy did not specifically include notification of the State Agency at 406-444-4170 whenever the fire alarm system was out of service for more than 4 hours in a 24 hour period.