HospitalInspections.org

K017

A) Based upon random observation, the surveyor finds that spaces open to corridors do not comply with 19.3.6.1:

1) The 1989 Building has a main entrance, reception, waiting area that is a required exit access corridor. This space is not staffed (observed) 24/7. The reception area, the waiting area and a nearby copy room (with no door), all lack smoke detection in accordance with exception # 1 under 19.3.6.1.

B) Four of four floors of the 1989 Building have a plenum return air system and do not comply with 19.3.6.2.1 of NFPA 101. In most portions of each floor every room communicates above the ceiling to every other room with a plenum return air system. This plenum return air system communicates to the nurse's station and rooms around the nurse's station on each floor. None of the rooms on each floor communicate directly to the exit access corridors, except at the nurse's stations. The nurse's station on the 2nd, 3rd and 4th floors are open to the exit access corridor of each floor.

1) The East Wing/smoke compartment on the 2nd, 3rd and 4th Floors have rooms that are separated from the exit access corridor in accordance with 19.3.6.2.1, exception # 1.

However, the smoke compartment has deficiencies cited under K104 and the shaft enclosure at the end of the wing (next to the stair) is deficient - see K067. These issues will affect how K017 is corrected in the adjacent, non-complying smoke compartments.

2) The other smoke compartment on 2nd, 3rd and 4th Floors incudes the nurse's station. elevator foyer and the West Wing. The nurse's station communicates to all rooms through a plenum return air system and the nurse's station communicates to the entire exit access corridor in this smoke compartment. This arrangement does not comply with any part of 19.3.6.2.1 and does not comply with 19.3.6.2.2 (the exit access corridor is not separated from all other spaces by smoke tight construction).

3) Sleeved unducted openings above the ceilings in some of the rooms identified above have fire dampers installed in sleeves that match the wall thickness. These openings are not protected with smoke dampers with smoke detectors that are designed to maintain a smoke tight separation between all such spaces and the exit access corridors in accordance with 19.3.6.2.2. The extent of this condition could not be determined. Full access to all rooms could not be provided; the were occupied by patients.

4) Sleeved unducted openings above the ceilings in some locations (some of which are designated smoke barriers, other are not in smoke barriers) have smoke dampers installed in sleeves that match the wall thickness. These openings are not protected with smoke dampers with smoke detectors that are designed to maintain a smoke tight separation between all such spaces and the exit access corridors in accordance with 19.3.6.2.2. Smoke detection installed below or above ceilings on these floors are minimal or non-existent.

5) The 1st Floor corridor wall at Classroom 115 is also a designated smoke barrier. The wall has a plenum return air transfer opening above the ceiling. A fire damper is installed in the opening instead of a smoke damper. The wall is not smoke tight to the deck above in accordance with 19.3.6.2.2. The plenum return air opening in the wall lacks a smoke damper and smoke detection.

6) The 1st Floor Administration Office has a wall that stops at the ceiling. All of the spaces in this area have plenum return air openings in the ceilings. The Administration Office lack corridor walls that comply with 19.3.6.2.2.

7) The designated smoke barrier and corridor wall between the Reception Desk and the Therapist's Office has a plenum return air transfer opening in the wall above the ceiling. A smoke detector is installed in the opening; however no smoke detection is installed to comply with NFPA 90A and in accordance with 19.3.6.2.2.

8) The wall between the Reception Area and the Therapist office is only accessible from one side. Multiple penetrations of this designated smoke barrier are not sealed for fire rated construction

See also K67 and K104 - The scope of the deficiency cannot be cited under one tag. The correction of each needs to be coordinated with all of the deficiencies cited K017, K067 and K104, in order to fully correct each item.

Failure to maintain exit access corridors in accordance with NFPA 101 will result in migration of smoke throughout the building in a fire emergency.

Submittal as a project for any proposed corrective action will be required.

End

K018

A) Based on observation the surveyor finds that one corridor door has latching hardware that is not maintained in accordance with 19.3.6.3.2.

The 1st Floor door to the Dining Room (west corridor door) has hardware that does not always latch.

Failure to maintain latching doors could also smoke to spread into the corridor during a fire.

End

K020

A) Based on random observation, the surveyor finds that vertical openings are not installed and maintained in accordance with 19.3.1.1. Findings include:

1) Mechanical Room 500 (west Penthouse) has a designated shaft enclosure with a two hour fire rating. There is a 12" x 16" hole in the shaft that lacks opening protection. The mechanical room is open to the shaft and the plenum return air system for the building. The hole in the shaft does not comply with 8.2.3.2 of NFPA 101.

2) The provider's construction documents indicate that the elevator shaft is enclosed in two hour fire rated construction. Based upon observation at random locations at the shaft elevator doors, the surveyor finds that the elevator shaft in the 1989 Building is not enclosed in two hour fire rated construction. Evidence includes:

a) The provider was not able to provide full access at the time of this survey.

b) The surveyor also observed that the shaft enclosure at the 3rd Floor Elevator lobby (above the elevator doors) was not sealed to a fire proofed structural beam above.

c) The surveyor also observed that the shaft wall next to the elevator doors appeared to be drywalled on one side only. The details or information that show how this wall was constructed and/or how the construction observed constitutes a two hour shaft wall was not available.

3) The provider's construction documents indicate that the duct shafts are
enclosed in two hour fire rated construction. The duct shaft next the 2 West stair is not constructed as a two hour fire rated enclosure:

a) A corner of the shaft above the ceiling
at the outside wall has a large void; the
shaft is open to the ceiling cavity of
the room.

b) Multiple penetrations into the shaft
above the ceiling are not sealed for
fire rated construction.

4) There is a mechanical mezzanine above a 1st Floor Maintenance Space, between the Gym and the Kitchen. This "mezzanine" does not comply with NFPA 101, Section 8.2 and NFPA 90A:

a) The mezzanine does not meet the
requirements of a mezzanine. The space
is open to the 1st Floor hazardous area
below via a 3' x 8' floor opening with a
ships ladder. The floor opening is an
unprotected opening between two floors
and does not comply with 8.2.5 of NFPA
101.

b) The 1st Floor space below the
mezzanine is a hazardous area
that is not separated from the mechanical
(mezzanine) space above.

c) In the mezzanine, there are
duct penetrations through the
floor and through a designated two hour
fire wall (for the Gym). The
construction documents
identify fire dampers at all duct
penetrations from this space. Fire
dampers were not found at the floor
penetrations and at the wall penetrations
in accordance with NFPA 90A.

5) The 1st Floor Stair door has a vision panel in the at the South Exit. The door is a B Label, one hour door; fire rated glazing for a B Label door is not provided in accordance with 18.2.3.2.3.1.

Submittal as a project for any proposed corrective action will be required.

Unprotected openings in vertical enclosures will allow heat and smoke to spread from floor to floor and will compromise that means of egress on multiple floors.

End

K025

A) Based on random observation the surveyor finds that smoke barriers are not constructed as one hour fire rated smoke barriers to the deck above (or they are not 1/2 fire rated construction to the deck above, where applicable for existing smoke barriers). Findings include:

1) 4th Floor Nurse's Station: The designated smoke wall, between the 4 East Day Room and the Nurse's Station Staff Break Room (at the back of the Nurse's Station, is only drywalled one one side, above the ceiling.
2) Inspection of smoke barriers above ceilings was limited by monolithic ceilings and by patient occupied spaces. Based upon the above finding, the survey expects to find similar conditions in a few other smoke barrier locations.

3) Smoke barriers are not constructed as 1/2 hour fire barriers in accordance with 19.3.7.3:

a) The designated cross corridor smoke doors on 3 East (near the Quiet Rooms) has multiple penetrations above the ceiling that are not sealed for fire rated construction.

b) The designated cross corridor smoke doors on 2 East (near the Quiet Rooms) has multiple penetrations above the ceiling that are not sealed for fire rated construction.

c) The designated 1st Floor smoke barrier at the cross corridor doors near Classroom 115 has multiple penetrations above the ceiling that are sealed with unrated materials (drywall mud). Also the wall is drywalled only on one side at the top of the wall.

d) The designated smoke barrier/corridor wall at Class Room 115 has multiple penetrations above the ceiling that are not sealed for fire rated construction

Failure to provide and maintain fire rated smoke barriers could allow fire and smoke to spread throughout patient areas.

End

K026

A) Based upon random observation, the surveyor finds that glazing in designated smoke barriers does not comply with 19.3.7.5 of NFPA 101.

The 1st Floor A & R Waiting Room has a steel frame and glass wall that is part of the designated one smoke barrier between the 1989 Building and the 2009 building. The smoke has a door has a full lite vision panel that is not not fire rated and full panel glazing in the designated smoke wall is not fire rated.

Lack of fire rated glazing could cause failure of the smoke barrier during a fire.

End

K028

A) Based upon random observation on multiple floors, the survey finds that single smoke doors in corridor walls and pair of cross corridor doors in designated smoke barriers have vision panels that are not wire glass or fire rated glazing. From observation the surveyor finds that many of the doors have vision panels that are plastic, laminated glass or tempered glass. Locations include but are not limited to:

1) Two of two Quiet Room, corridor doors in the designated smoke barrier of the East Wing, near the nurse's station.

2) The Four East Day room has a single corridor door in a smoke barrier with unrated glazing.

3) Two of two Quiet Rooms on 3 East

4) 3 East Day Room

5) Two of two Quiet Rooms on 2 East

6) 2 East Day Room

7) The 1st Floor Classroom (near the Gym) has a corridor wall that is a designated smoke barrier. Door 115B is a designated smoke door with a non fire rated vision panel.

End

K029

A) Based on random observation the surveyor finds that hazardous areas are not enclosed in accordance with 19.3.2.1:

1) The Clean Utility Room in the 4th Floor Nurse's Station has a door with latching hardware that does not latch. The door lacks latching hardware that complies with NFPA 80.

2) The 4 West Storage Room, the 4th Floor Clean Utility Room (at the Nurse's Station) and the 4th Floor Soiled Utility Room (at the Nurse's Station) have unducted, plenum return air openings in the ceiling and the enclosure walls. Although some but not all plenum return air openings have smoke dampers, the smoke dampers are not installed and maintained to provide a smoke tight enclosure in accordance with 19.3.2.1.

3) The Clean Utility Room and the Soiled Utility Room in the 3rd Floor Nurse's Station both have doors with latching hardware that does not latch. The doors lack latching hardware that comply with 19.3.2.1 of NFPA 101 and NFPA 80.

3) The 3 West Storage Room, the 3rd Floor Clean Utility Room (at the Nurse's Station) and the 3rd Floor Soiled Utility Room (at the Nurse's Station) have unducted, plenum return air openings in the ceiling and the enclosure walls. Although some but not all plenum return air openings have smoke dampers, the smoke dampers are not installed and maintained to provide a smoke tight enclosure in accordance with 19.3.2.1.

4) The 2 West Storage Room, the 2nd Floor Clean Utility Room (at the Nurse's Station) and the 2nd Floor Soiled Utility Room (at the Nurse's Station) have unducted, plenum return air openings in the ceiling and the enclosure walls. Although some but not all plenum return air openings have smoke dampers, the smoke dampers are not installed and maintained to provide a smoke tight enclosure in accordance with 19.3.2.1.

5) The 1st Floor Corridor door east of the Gym is marked "Office;" however it is really another door to the Maintenance Shop and is designated as a hazardous area with a one hour fire rated enclosure. The corridor door (marked Office) is a 20 minute door instead of a 3/4 hour fire door. The vision panel in the door is not fire rated glazing and the continuous hinge on the door has no listing identifying it as approved hardware for a fire door.

6) The east corridor door to the Maintenance Shop is located in a designated one hour wall. The door lacks a U L Label identifying it as a 3/4 hour fire door.

7) The 1st Floor Clean Linen Room Corridor door near the Kitchen is not self closing (closing device has been removed).

8) The 1st Floor Medical Records Storage Room has a 20 minute door instead of a 3/4 hour fire rated door.

9) All patient laundry rooms on all floors of the four story building are required to comply as hazardous area. These rooms are sprinklered but lack a smoke tight enclosure in accordance with NFPA 101 -19.3.1.1.

a) The door to the corridor is not self closing

b) The rooms have have a ducted system with a fire damper installed at the penetration into an adjacent shaft enclosure. The same duct also penetrates into adjacent rooms above the ceilings. Access above the ceilings in the adjacent rooms could not be provided - all adjacent rooms have monolithic ceilings. The surveyor is not able to confirm that this is not part of a plenum return air system that communicates to multiple floors and the exit access corridor

c. A combination fire/smoke damper is not installed at the shaft penetration with smoke detection installed in accordance with NFPA 72 and NFPA 90A.

d. The duct penetrations into adjacent rooms lack smoke dampers and smoke detection in accordance with NFPA 90A.

Failure to install and maintain smoke tight enclosures for hazardous areas could allow smoke to migrate to all patient areas and corridors during a fire emergency.

End

K038

A) Based on observation that surveyor finds that one room has a locking device that does not comply with 7.2.1.5.4.

The 1st Floor Dining Room has a separate tray return space. The door to this space had a locking device mounted high on the door with a hasp and a lock that requires use of a key to open. The locking device lacked a releasing device inside the space. A patient could be locked inside the space. The locking device does not comply with CMS's requirements for patient accessible areas and the space is not designed to be a patient observation room.

A patient could be accidently locked inside a space with no way out. This condition was abated by the provider on the day that the deficiency was observed.

End

K044

A) Based on random observation, the surveyor finds that two hour fire barriers are not installed and maintained in accordance with 7.2.4:

1) The 1st Floor Gym is identified with a two hour fire barrier around it. The corridor door in the designated two hour wall lack a U L Label as a 1 1/2 hour fire door and the vision panel in the door is plastic and not fire rated glazing in accordance with NFPA 80.

Failure to install and maintain fire rated assemblies could result in failure of that assembly prematurely in a fire emergency.

End

K047

A) Based on random observation the surveyor finds that illuminated exit signs are not installed where required in a few locations. Findings include:

1) There is a 1st Floor elevator foyer/vestibule that is part of the means of egress (between the conference room and reception desk. This vestibule lacks exit signs identifying two remote paths of egress from this space. The surveyor notes that one wall mounted exit sign lack illuminated chevrons that identify the exit path.

Failure to install and maintain exit signs could cause confusion in an emergency.

End

K051

A) Based on random observation, the surveyor finds that the fire alarm system is not installed and maintained in accordance with NFPA 72

1) The provider has some heat detectors installed that look exactly like smoke detectors. The provider and/or the surveyor is not able to identify which are heat detectors and which are smoke detectors without climbing a ladder or testing the device. The heat detectors lack markings that distinguish them as heat detectors in accordance with 3.2.1.1 of NFPA 72 - 1999.

End



17659

K051

B) Based on random observation during the survey walk through, not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

Findings include:

1) Smoke detectors in elevator lobbies are not separated from air supply diffusers by at least 3'-0" as required by NFPA-72, Section 2-3.5.1.

2). The circuit breakers serving the fire alarm system are not marked in red as required by NFPA-72, Section 1-5.2.5.2.

End

K056

A) Based on random observation, the surveyor finds that sprinkler systems are not installed and maintained in accordance with NFPA 101 and NFPA 13. Findings include:

1) 1st Floor Medical Records Forms Closet (opposite from Room 115). The room lacks sprinkler protection. The facility uses exceptions under NFPA 101 for fully sprinklered buildings. The building is not fully sprinklered with the sprinkler head missing in this room.

Lack of sprinkler protection will allow fire to spread more quickly through the building.

2) Based on random observation and personnel interview, the surveyor finds the multiple inspector's test valves are not designed and installed to simulate the flow of one sprinkler head (example: inspector's test valve in the 1st Floor Northwest Stair). Other similar locations were observed but not listed. Based on the deficient locations observed all locations are expected to be deficient.

Calibration of flow switches and activation of the fire alarm system may be delayed if testing is not conducted in accordance with NFPA 13/NFPA 23.

The surveyor also observed that the above deficiencies are not being found and abated on annual sprinlker system testing, maintenance and servicing, in accordance with NFPA 13/NFPA 25.

End

K062

Based on document review on the morning of April 24, 2012, not all portions of the facility's sprinkler system are tested and maintained in accordance with NFPA 25 1998 and NFPA 72 1999. Documenation for the previous tweve months was reviewed

Findings include:

A. During record review, sprinkler flow switches were documented by a simple statement as tested. Flow switch testing did not show the individual test of each flow switch in accordance with 25 2-3.3.1.

B. During record review sprinkler flow switches were documented by tested and no alarm activation time documented to show compliance with 72 2-6.2 for alarm activation in less than 90 seconds.

Not properly testing the devices can lead to component failure and could injure patients.

End

K067

A) Based on random observation the surveyor finds that mechanical (HVAC) systems, devices and materials are not installed in accordance with NFPA 90A - 1999.

1) A Kitchen roof top air handling unit has an air intake that is closer that 15 feet to an exhaust fan and a plumbing vent through roof.

Hazardous exhaust or fumes could enter the air intake for the Kitchen and compromise the air and ventilation system in the kitchen

2) A 1st Floor corridor in 1 West has a fire damper (FD1-2) that is installed in a ducted supply air system. The duct is not installed with retaining angles in accordance with a tested design for fire dampers.

Failure to install and maintain fire damper assemblies could cause fail and the spread of fire above ceiling spaces.

3) The 1989 Building has two 5th Floor Mechanical Penthouses with an air handling unit in each. The East HVAC units is over 15,000 cfm and the system lacks smoke detection and combination smoke/ fire dampers installed at the return air penetration into the shaft on every floor, in accordance with Section 4-42 of NFPA 90A - 1999. HVAC system shut down and smoke detection on every floor is not provided. The surveyors observed smoke detection and dampers above the ceiling floor ceiling at the shaft but did not find them on the 1st Floor

Submittal as a project for any proposed corrective action will be required.

Failure to shut HVAC equipment down in accordance with NFPA 90A will result in smoke movement to multiple floors in a fire emergency.

End

K069

A) Based upon random observation and document review the surveyor finds that two semi-annual hood suppression testing and maintenance documentation of the past 16 months does not comply with NFPA 17A and NFPA 96:

1) The documentation for semi annual testing and maintenance (current certificate and previous certificate) identifies testing of a dry chemical suppression system; however the system installed is a wet chemical system.

Inaccurate documentation could result in improper testing and failure of the system.

End

K104

A) Based on random observation, personnel interview and document review the surveyor finds that although the 1989 building is fully sprinklered, it does not comply with the exception under 19.3.7.3. The entire building has a plenum return air system (unducted system) above ceilings. Smoke dampers at all penetrations though smoke barriers are required but are not provided in accordance with 8.3.5 of NFPA 101 -2000.

1) Although smoke dampers are installed in some but not all required locations the smoke dampers are not installed in accordance with 8.3.5 the dampers lack smoke detection in accordance with 8.3.5 and NFPA 72.

a) Locations where smoke dampers are installed but that lack smoke detection include but are not limited to the smoke barriers at the nurse's station wall at 2 East, 3 East and 4 East.

b) Locations where smoke dampers are not installed include but are not necessarily limited to 1st Floor Room 115.

c) In some locations, the surveyor observes that plenum return air openings have fire dampers installed where smoke dampers with smoke detection are required (see also K17). In some cases fire dampers were found where combination fire/smoke dampers may be required (see K104).

Failure to install and maintain smoke dampers in accordance with NFPA 101 and NFPA 90A will result in the migration of smoke to multiple locations on each floor in a fire emergency.

B) Vertical openings do not limit the travel of smoke from floor to floor to floor in accordance with 8.2 and 8.3 of NFPA 101: Locations include:

1) There is a duct shaft next to the exit stair on each floor (at the end of each wing). Each duct shaft communicates to a small 5th Floor Mechanical Penthouse. The supply and return air in each penthouse are fully ducted within the penthouse. The supply air duct in each shaft is fully ducted within the shaft and throughout each floor. Each supply air duct for these two systems has fire dampers where each duct penetrates the duct shaft.

However, the shaft enclosure from each 5th Floor penthouse is used as the return air duct (the supply air duct system is located inside of the return air duct. Two of two shafts have plenum return air openings on each floor with a fire damper installed at the opening into the shaft, above the ceiling on each floor. The fire dampers are not installed to resist the passage of smoke from floor to floor to floor (each smoke compartment on each floor communicates to every other floor via the plenum return air shafts).

Fire dampers and smoke dampers or combination fire/smoke dampers are not installed (with smoke detection at each plenum opening into each shaft) in accordance sections of NFPA 101 referenced.

The provider failed to provide any information that indicates that the above conditions are part of a smoke management or smoke control system.

Submittal as a project for any proposed corrective action will be required.

The lack of fire and smoke dampers for these shaft enclosures will allow smoke to pass from floor to floor to floor and will readily compromise all corridors and all rooms during a fire emergency.

End

K106

Based on random observation during the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

1. The 300 kw generator was not equipped with a battery heater to meet the requirements of NFPA-110, Section 3-3.1.

End

K145

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

1. The Life Safety Panels such as panel LSL1 are serving loads other than those allowed by NFPA-70, Section 517-32. Panel-LSL1 was serving computer room receptacles, the generator battery charger, the generator block heater, and the day tank heater. These items should be fed from the critical or equipment branch of the emergency power system in accordance with NFPA-70, Section 517-33, or 517-34. Life Safety Panels shall serve only the items allowed by NFPA-70, Section 517-32.

2. The elevator cab lighting disconnect was marked as being served by Panel-2ECL, Circuit 19. This is a critical panel designation, and elevator cab lighting is required to be served by the life safety branch of the emergency power system to meet the requirements of NFPA-70, section 517-32(f).

End

K147

A) Based on random observation, the surveyor finds that electrical installations systems and materials do not comply with NFPA 70. Findings include:

1) The 1st Floor main entrance lobby/waiting room has a television with an extension cord in permanent use.

End



17659

K147

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999). Improper grounding could create a shock hazard for all occupants of the building.

Findings include:

1. The water service, and the building steel in the new portion of the building were not bonded to ground in accordance with NFPA-70, Section 250-50.

2. The water meter in the new portion of the building was not equipped with a bonding jumper in accordance with NFPA-70, Section 250-68(b).

3. Panel schedules throughout the building were not accurate, circuit breakers in nearly every panel that were marked as spare were in the on position. This does not meet the requirements of NFPA-70, Section 110-22.

End

K017

A) Based upon random observation, the surveyor finds that spaces open to corridors do not comply with 19.3.6.1:

1) The 1989 Building has a main entrance, reception, waiting area that is a required exit access corridor. This space is not staffed (observed) 24/7. The reception area, the waiting area and a nearby copy room (with no door), all lack smoke detection in accordance with exception # 1 under 19.3.6.1.

B) Four of four floors of the 1989 Building have a plenum return air system and do not comply with 19.3.6.2.1 of NFPA 101. In most portions of each floor every room communicates above the ceiling to every other room with a plenum return air system. This plenum return air system communicates to the nurse's station and rooms around the nurse's station on each floor. None of the rooms on each floor communicate directly to the exit access corridors, except at the nurse's stations. The nurse's station on the 2nd, 3rd and 4th floors are open to the exit access corridor of each floor.

1) The East Wing/smoke compartment on the 2nd, 3rd and 4th Floors have rooms that are separated from the exit access corridor in accordance with 19.3.6.2.1, exception # 1.

However, the smoke compartment has deficiencies cited under K104 and the shaft enclosure at the end of the wing (next to the stair) is deficient - see K067. These issues will affect how K017 is corrected in the adjacent, non-complying smoke compartments.

2) The other smoke compartment on 2nd, 3rd and 4th Floors incudes the nurse's station. elevator foyer and the West Wing. The nurse's station communicates to all rooms through a plenum return air system and the nurse's station communicates to the entire exit access corridor in this smoke compartment. This arrangement does not comply with any part of 19.3.6.2.1 and does not comply with 19.3.6.2.2 (the exit access corridor is not separated from all other spaces by smoke tight construction).

3) Sleeved unducted openings above the ceilings in some of the rooms identified above have fire dampers installed in sleeves that match the wall thickness. These openings are not protected with smoke dampers with smoke detectors that are designed to maintain a smoke tight separation between all such spaces and the exit access corridors in accordance with 19.3.6.2.2. The extent of this condition could not be determined. Full access to all rooms could not be provided; the were occupied by patients.

4) Sleeved unducted openings above the ceilings in some locations (some of which are designated smoke barriers, other are not in smoke barriers) have smoke dampers installed in sleeves that match the wall thickness. These openings are not protected with smoke dampers with smoke detectors that are designed to maintain a smoke tight separation between all such spaces and the exit access corridors in accordance with 19.3.6.2.2. Smoke detection installed below or above ceilings on these floors are minimal or non-existent.

5) The 1st Floor corridor wall at Classroom 115 is also a designated smoke barrier. The wall has a plenum return air transfer opening above the ceiling. A fire damper is installed in the opening instead of a smoke damper. The wall is not smoke tight to the deck above in accordance with 19.3.6.2.2. The plenum return air opening in the wall lacks a smoke damper and smoke detection.

6) The 1st Floor Administration Office has a wall that stops at the ceiling. All of the spaces in this area have plenum return air openings in the ceilings. The Administration Office lack corridor walls that comply with 19.3.6.2.2.

7) The designated smoke barrier and corridor wall between the Reception Desk and the Therapist's Office has a plenum return air transfer opening in the wall above the ceiling. A smoke detector is installed in the opening; however no smoke detection is installed to comply with NFPA 90A and in accordance with 19.3.6.2.2.

8) The wall between the Reception Area and the Therapist office is only accessible from one side. Multiple penetrations of this designated smoke barrier are not sealed for fire rated construction

See also K67 and K104 - The scope of the deficiency cannot be cited under one tag. The correction of each needs to be coordinated with all of the deficiencies cited K017, K067 and K104, in order to fully correct each item.

Failure to maintain exit access corridors in accordance with NFPA 101 will result in migration of smoke throughout the building in a fire emergency.

Submittal as a project for any proposed corrective action will be required.

End

K018

A) Based on observation the surveyor finds that one corridor door has latching hardware that is not maintained in accordance with 19.3.6.3.2.

The 1st Floor door to the Dining Room (west corridor door) has hardware that does not always latch.

Failure to maintain latching doors could also smoke to spread into the corridor during a fire.

End

K020

A) Based on random observation, the surveyor finds that vertical openings are not installed and maintained in accordance with 19.3.1.1. Findings include:

1) Mechanical Room 500 (west Penthouse) has a designated shaft enclosure with a two hour fire rating. There is a 12" x 16" hole in the shaft that lacks opening protection. The mechanical room is open to the shaft and the plenum return air system for the building. The hole in the shaft does not comply with 8.2.3.2 of NFPA 101.

2) The provider's construction documents indicate that the elevator shaft is enclosed in two hour fire rated construction. Based upon observation at random locations at the shaft elevator doors, the surveyor finds that the elevator shaft in the 1989 Building is not enclosed in two hour fire rated construction. Evidence includes:

a) The provider was not able to provide full access at the time of this survey.

b) The surveyor also observed that the shaft enclosure at the 3rd Floor Elevator lobby (above the elevator doors) was not sealed to a fire proofed structural beam above.

c) The surveyor also observed that the shaft wall next to the elevator doors appeared to be drywalled on one side only. The details or information that show how this wall was constructed and/or how the construction observed constitutes a two hour shaft wall was not available.

3) The provider's construction documents indicate that the duct shafts are
enclosed in two hour fire rated construction. The duct shaft next the 2 West stair is not constructed as a two hour fire rated enclosure:

a) A corner of the shaft above the ceiling
at the outside wall has a large void; the
shaft is open to the ceiling cavity of
the room.

b) Multiple penetrations into the shaft
above the ceiling are not sealed for
fire rated construction.

4) There is a mechanical mezzanine above a 1st Floor Maintenance Space, between the Gym and the Kitchen. This "mezzanine" does not comply with NFPA 101, Section 8.2 and NFPA 90A:

a) The mezzanine does not meet the
requirements of a mezzanine. The space
is open to the 1st Floor hazardous area
below via a 3' x 8' floor opening with a
ships ladder. The floor opening is an
unprotected opening between two floors
and does not comply with 8.2.5 of NFPA
101.

b) The 1st Floor space below the
mezzanine is a hazardous area
that is not separated from the mechanical
(mezzanine) space above.

c) In the mezzanine, there are
duct penetrations through the
floor and through a designated two hour
fire wall (for the Gym). The
construction documents
identify fire dampers at all duct
penetrations from this space. Fire
dampers were not found at the floor
penetrations and at the wall penetrations
in accordance with NFPA 90A.

5) The 1st Floor Stair door has a vision panel in the at the South Exit. The door is a B Label, one hour door; fire rated glazing for a B Label door is not provided in accordance with 18.2.3.2.3.1.

Submittal as a project for any proposed corrective action will be required.

Unprotected openings in vertical enclosures will allow heat and smoke to spread from floor to floor and will compromise that means of egress on multiple floors.

End

K025

A) Based on random observation the surveyor finds that smoke barriers are not constructed as one hour fire rated smoke barriers to the deck above (or they are not 1/2 fire rated construction to the deck above, where applicable for existing smoke barriers). Findings include:

1) 4th Floor Nurse's Station: The designated smoke wall, between the 4 East Day Room and the Nurse's Station Staff Break Room (at the back of the Nurse's Station, is only drywalled one one side, above the ceiling.
2) Inspection of smoke barriers above ceilings was limited by monolithic ceilings and by patient occupied spaces. Based upon the above finding, the survey expects to find similar conditions in a few other smoke barrier locations.

3) Smoke barriers are not constructed as 1/2 hour fire barriers in accordance with 19.3.7.3:

a) The designated cross corridor smoke doors on 3 East (near the Quiet Rooms) has multiple penetrations above the ceiling that are not sealed for fire rated construction.

b) The designated cross corridor smoke doors on 2 East (near the Quiet Rooms) has multiple penetrations above the ceiling that are not sealed for fire rated construction.

c) The designated 1st Floor smoke barrier at the cross corridor doors near Classroom 115 has multiple penetrations above the ceiling that are sealed with unrated materials (drywall mud). Also the wall is drywalled only on one side at the top of the wall.

d) The designated smoke barrier/corridor wall at Class Room 115 has multiple penetrations above the ceiling that are not sealed for fire rated construction

Failure to provide and maintain fire rated smoke barriers could allow fire and smoke to spread throughout patient areas.

End

K026

A) Based upon random observation, the surveyor finds that glazing in designated smoke barriers does not comply with 19.3.7.5 of NFPA 101.

The 1st Floor A & R Waiting Room has a steel frame and glass wall that is part of the designated one smoke barrier between the 1989 Building and the 2009 building. The smoke has a door has a full lite vision panel that is not not fire rated and full panel glazing in the designated smoke wall is not fire rated.

Lack of fire rated glazing could cause failure of the smoke barrier during a fire.

End

K028

A) Based upon random observation on multiple floors, the survey finds that single smoke doors in corridor walls and pair of cross corridor doors in designated smoke barriers have vision panels that are not wire glass or fire rated glazing. From observation the surveyor finds that many of the doors have vision panels that are plastic, laminated glass or tempered glass. Locations include but are not limited to:

1) Two of two Quiet Room, corridor doors in the designated smoke barrier of the East Wing, near the nurse's station.

2) The Four East Day room has a single corridor door in a smoke barrier with unrated glazing.

3) Two of two Quiet Rooms on 3 East

4) 3 East Day Room

5) Two of two Quiet Rooms on 2 East

6) 2 East Day Room

7) The 1st Floor Classroom (near the Gym) has a corridor wall that is a designated smoke barrier. Door 115B is a designated smoke door with a non fire rated vision panel.

End

K029

A) Based on random observation the surveyor finds that hazardous areas are not enclosed in accordance with 19.3.2.1:

1) The Clean Utility Room in the 4th Floor Nurse's Station has a door with latching hardware that does not latch. The door lacks latching hardware that complies with NFPA 80.

2) The 4 West Storage Room, the 4th Floor Clean Utility Room (at the Nurse's Station) and the 4th Floor Soiled Utility Room (at the Nurse's Station) have unducted, plenum return air openings in the ceiling and the enclosure walls. Although some but not all plenum return air openings have smoke dampers, the smoke dampers are not installed and maintained to provide a smoke tight enclosure in accordance with 19.3.2.1.

3) The Clean Utility Room and the Soiled Utility Room in the 3rd Floor Nurse's Station both have doors with latching hardware that does not latch. The doors lack latching hardware that comply with 19.3.2.1 of NFPA 101 and NFPA 80.

3) The 3 West Storage Room, the 3rd Floor Clean Utility Room (at the Nurse's Station) and the 3rd Floor Soiled Utility Room (at the Nurse's Station) have unducted, plenum return air openings in the ceiling and the enclosure walls. Although some but not all plenum return air openings have smoke dampers, the smoke dampers are not installed and maintained to provide a smoke tight enclosure in accordance with 19.3.2.1.

4) The 2 West Storage Room, the 2nd Floor Clean Utility Room (at the Nurse's Station) and the 2nd Floor Soiled Utility Room (at the Nurse's Station) have unducted, plenum return air openings in the ceiling and the enclosure walls. Although some but not all plenum return air openings have smoke dampers, the smoke dampers are not installed and maintained to provide a smoke tight enclosure in accordance with 19.3.2.1.

5) The 1st Floor Corridor door east of the Gym is marked "Office;" however it is really another door to the Maintenance Shop and is designated as a hazardous area with a one hour fire rated enclosure. The corridor door (marked Office) is a 20 minute door instead of a 3/4 hour fire door. The vision panel in the door is not fire rated glazing and the continuous hinge on the door has no listing identifying it as approved hardware for a fire door.

6) The east corridor door to the Maintenance Shop is located in a designated one hour wall. The door lacks a U L Label identifying it as a 3/4 hour fire door.

7) The 1st Floor Clean Linen Room Corridor door near the Kitchen is not self closing (closing device has been removed).

8) The 1st Floor Medical Records Storage Room has a 20 minute door instead of a 3/4 hour fire rated door.

9) All patient laundry rooms on all floors of the four story building are required to comply as hazardous area. These rooms are sprinklered but lack a smoke tight enclosure in accordance with NFPA 101 -19.3.1.1.

a) The door to the corridor is not self closing

b) The rooms have have a ducted system with a fire damper installed at the penetration into an adjacent shaft enclosure. The same duct also penetrates into adjacent rooms above the ceilings. Access above the ceilings in the adjacent rooms could not be provided - all adjacent rooms have monolithic ceilings. The surveyor is not able to confirm that this is not part of a plenum return air system that communicates to multiple floors and the exit access corridor

c. A combination fire/smoke damper is not installed at the shaft penetration with smoke detection installed in accordance with NFPA 72 and NFPA 90A.

d. The duct penetrations into adjacent rooms lack smoke dampers and smoke detection in accordance with NFPA 90A.

Failure to install and maintain smoke tight enclosures for hazardous areas could allow smoke to migrate to all patient areas and corridors during a fire emergency.

End

K038

A) Based on observation that surveyor finds that one room has a locking device that does not comply with 7.2.1.5.4.

The 1st Floor Dining Room has a separate tray return space. The door to this space had a locking device mounted high on the door with a hasp and a lock that requires use of a key to open. The locking device lacked a releasing device inside the space. A patient could be locked inside the space. The locking device does not comply with CMS's requirements for patient accessible areas and the space is not designed to be a patient observation room.

A patient could be accidently locked inside a space with no way out. This condition was abated by the provider on the day that the deficiency was observed.

End

K044

A) Based on random observation, the surveyor finds that two hour fire barriers are not installed and maintained in accordance with 7.2.4:

1) The 1st Floor Gym is identified with a two hour fire barrier around it. The corridor door in the designated two hour wall lack a U L Label as a 1 1/2 hour fire door and the vision panel in the door is plastic and not fire rated glazing in accordance with NFPA 80.

Failure to install and maintain fire rated assemblies could result in failure of that assembly prematurely in a fire emergency.

End

K047

A) Based on random observation the surveyor finds that illuminated exit signs are not installed where required in a few locations. Findings include:

1) There is a 1st Floor elevator foyer/vestibule that is part of the means of egress (between the conference room and reception desk. This vestibule lacks exit signs identifying two remote paths of egress from this space. The surveyor notes that one wall mounted exit sign lack illuminated chevrons that identify the exit path.

Failure to install and maintain exit signs could cause confusion in an emergency.

End

K051

A) Based on random observation, the surveyor finds that the fire alarm system is not installed and maintained in accordance with NFPA 72

1) The provider has some heat detectors installed that look exactly like smoke detectors. The provider and/or the surveyor is not able to identify which are heat detectors and which are smoke detectors without climbing a ladder or testing the device. The heat detectors lack markings that distinguish them as heat detectors in accordance with 3.2.1.1 of NFPA 72 - 1999.

End



17659

K051

B) Based on random observation during the survey walk through, not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

Findings include:

1) Smoke detectors in elevator lobbies are not separated from air supply diffusers by at least 3'-0" as required by NFPA-72, Section 2-3.5.1.

2). The circuit breakers serving the fire alarm system are not marked in red as required by NFPA-72, Section 1-5.2.5.2.

End

K056

A) Based on random observation, the surveyor finds that sprinkler systems are not installed and maintained in accordance with NFPA 101 and NFPA 13. Findings include:

1) 1st Floor Medical Records Forms Closet (opposite from Room 115). The room lacks sprinkler protection. The facility uses exceptions under NFPA 101 for fully sprinklered buildings. The building is not fully sprinklered with the sprinkler head missing in this room.

Lack of sprinkler protection will allow fire to spread more quickly through the building.

2) Based on random observation and personnel interview, the surveyor finds the multiple inspector's test valves are not designed and installed to simulate the flow of one sprinkler head (example: inspector's test valve in the 1st Floor Northwest Stair). Other similar locations were observed but not listed. Based on the deficient locations observed all locations are expected to be deficient.

Calibration of flow switches and activation of the fire alarm system may be delayed if testing is not conducted in accordance with NFPA 13/NFPA 23.

The surveyor also observed that the above deficiencies are not being found and abated on annual sprinlker system testing, maintenance and servicing, in accordance with NFPA 13/NFPA 25.

End

K062

Based on document review on the morning of April 24, 2012, not all portions of the facility's sprinkler system are tested and maintained in accordance with NFPA 25 1998 and NFPA 72 1999. Documenation for the previous tweve months was reviewed

Findings include:

A. During record review, sprinkler flow switches were documented by a simple statement as tested. Flow switch testing did not show the individual test of each flow switch in accordance with 25 2-3.3.1.

B. During record review sprinkler flow switches were documented by tested and no alarm activation time documented to show compliance with 72 2-6.2 for alarm activation in less than 90 seconds.

Not properly testing the devices can lead to component failure and could injure patients.

End

K067

A) Based on random observation the surveyor finds that mechanical (HVAC) systems, devices and materials are not installed in accordance with NFPA 90A - 1999.

1) A Kitchen roof top air handling unit has an air intake that is closer that 15 feet to an exhaust fan and a plumbing vent through roof.

Hazardous exhaust or fumes could enter the air intake for the Kitchen and compromise the air and ventilation system in the kitchen

2) A 1st Floor corridor in 1 West has a fire damper (FD1-2) that is installed in a ducted supply air system. The duct is not installed with retaining angles in accordance with a tested design for fire dampers.

Failure to install and maintain fire damper assemblies could cause fail and the spread of fire above ceiling spaces.

3) The 1989 Building has two 5th Floor Mechanical Penthouses with an air handling unit in each. The East HVAC units is over 15,000 cfm and the system lacks smoke detection and combination smoke/ fire dampers installed at the return air penetration into the shaft on every floor, in accordance with Section 4-42 of NFPA 90A - 1999. HVAC system shut down and smoke detection on every floor is not provided. The surveyors observed smoke detection and dampers above the ceiling floor ceiling at the shaft but did not find them on the 1st Floor

Submittal as a project for any proposed corrective action will be required.

Failure to shut HVAC equipment down in accordance with NFPA 90A will result in smoke movement to multiple floors in a fire emergency.

End

K069

A) Based upon random observation and document review the surveyor finds that two semi-annual hood suppression testing and maintenance documentation of the past 16 months does not comply with NFPA 17A and NFPA 96:

1) The documentation for semi annual testing and maintenance (current certificate and previous certificate) identifies testing of a dry chemical suppression system; however the system installed is a wet chemical system.

Inaccurate documentation could result in improper testing and failure of the system.

End

K104

A) Based on random observation, personnel interview and document review the surveyor finds that although the 1989 building is fully sprinklered, it does not comply with the exception under 19.3.7.3. The entire building has a plenum return air system (unducted system) above ceilings. Smoke dampers at all penetrations though smoke barriers are required but are not provided in accordance with 8.3.5 of NFPA 101 -2000.

1) Although smoke dampers are installed in some but not all required locations the smoke dampers are not installed in accordance with 8.3.5 the dampers lack smoke detection in accordance with 8.3.5 and NFPA 72.

a) Locations where smoke dampers are installed but that lack smoke detection include but are not limited to the smoke barriers at the nurse's station wall at 2 East, 3 East and 4 East.

b) Locations where smoke dampers are not installed include but are not necessarily limited to 1st Floor Room 115.

c) In some locations, the surveyor observes that plenum return air openings have fire dampers installed where smoke dampers with smoke detection are required (see also K17). In some cases fire dampers were found where combination fire/smoke dampers may be required (see K104).

Failure to install and maintain smoke dampers in accordance with NFPA 101 and NFPA 90A will result in the migration of smoke to multiple locations on each floor in a fire emergency.

B) Vertical openings do not limit the travel of smoke from floor to floor to floor in accordance with 8.2 and 8.3 of NFPA 101: Locations include:

1) There is a duct shaft next to the exit stair on each floor (at the end of each wing). Each duct shaft communicates to a small 5th Floor Mechanical Penthouse. The supply and return air in each penthouse are fully ducted within the penthouse. The supply air duct in each shaft is fully ducted within the shaft and throughout each floor. Each supply air duct for these two systems has fire dampers where each duct penetrates the duct shaft.

However, the shaft enclosure from each 5th Floor penthouse is used as the return air duct (the supply air duct system is located inside of the return air duct. Two of two shafts have plenum return air openings on each floor with a fire damper installed at the opening into the shaft, above the ceiling on each floor. The fire dampers are not installed to resist the passage of smoke from floor to floor to floor (each smoke compartment on each floor communicates to every other floor via the plenum return air shafts).

Fire dampers and smoke dampers or combination fire/smoke dampers are not installed (with smoke detection at each plenum opening into each shaft) in accordance sections of NFPA 101 referenced.

The provider failed to provide any information that indicates that the above conditions are part of a smoke management or smoke control system.

Submittal as a project for any proposed corrective action will be required.

The lack of fire and smoke dampers for these shaft enclosures will allow smoke to pass from floor to floor to floor and will readily compromise all corridors and all rooms during a fire emergency.

End

K106

Based on random observation during the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

1. The 300 kw generator was not equipped with a battery heater to meet the requirements of NFPA-110, Section 3-3.1.

End

K145

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

1. The Life Safety Panels such as panel LSL1 are serving loads other than those allowed by NFPA-70, Section 517-32. Panel-LSL1 was serving computer room receptacles, the generator battery charger, the generator block heater, and the day tank heater. These items should be fed from the critical or equipment branch of the emergency power system in accordance with NFPA-70, Section 517-33, or 517-34. Life Safety Panels shall serve only the items allowed by NFPA-70, Section 517-32.

2. The elevator cab lighting disconnect was marked as being served by Panel-2ECL, Circuit 19. This is a critical panel designation, and elevator cab lighting is required to be served by the life safety branch of the emergency power system to meet the requirements of NFPA-70, section 517-32(f).

End

K147

A) Based on random observation, the surveyor finds that electrical installations systems and materials do not comply with NFPA 70. Findings include:

1) The 1st Floor main entrance lobby/waiting room has a television with an extension cord in permanent use.

End



17659

K147

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999). Improper grounding could create a shock hazard for all occupants of the building.

Findings include:

1. The water service, and the building steel in the new portion of the building were not bonded to ground in accordance with NFPA-70, Section 250-50.

2. The water meter in the new portion of the building was not equipped with a bonding jumper in accordance with NFPA-70, Section 250-68(b).

3. Panel schedules throughout the building were not accurate, circuit breakers in nearly every panel that were marked as spare were in the on position. This does not meet the requirements of NFPA-70, Section 110-22.

End