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Based on observation and interview with staff, the facility failed to provide latching hardware on doors protecting corridor openings. 18.3.6.3. Findings:


1) The double doors leading into the Surgery Suite do not have positive latching hardware.

Based on observation and interview with staff, the facility failed to provide smoke barriers that provide at least a one-hour fire resistance rating. Findings:

The smoke compartment wall (smoke barrier) does not meet the separation requirement at the following locations. (Note: these locations are not all-inclusive. The facility shall inspect all smoke barriers to determine additional unrated penetrations, etc.)

1) First Floor: An unrated corner exists in the wall between Surgery Holding 145 and G.I. Holding.

2) First Floor: An unrated metal support channel penetration exists in the wall between Trauma 1E07 and the adjacent corridor.

3) Second Floor: A square duct is not fire sealed above the door between the Atrium Lobby (Smoke Compartment 4) and the Vestibule (Smoke Compartment 3).

4) Second Floor: A square duct is not fire sealed over the double egress doors between Smoke Compartment 2 and Smoke Compartment 3.

5) Third Floor: Conduit is not fire sealed above the double egress doors between Smoke Compartment 1 and Smoke Compartment 3.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected by one hour fire rated construction. Findings:

1) Exam Room 1 (1K02 on floor plan sheet provided to surveyor) is now used as a Storage Room, is larger than 100 square feet, and is considered a hazardous area per Table 18.3.7.1 Hazardous Area Protection. This Storage Room is required to be protected by one-hour construction per 18.3.7.1.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system that is inspected periodically. Findings:

1) First Floor: Wires were found resting upon fire sprinkler piping at the east end of the corridor outside of Radiology, in violation of NFPA 25, 5.2.2.2

2) Third Floor Marketing Closet: The facility failed to provide 18" clear of obstructions below the sprinkler deflectors, in violation of NFPA 13, 5-5.5.3.

Based on observation and interview with staff, the facility failed to provide mean of egress continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency. Refer to 7.1.10. Findings.

1) The Surgery Suite Restricted Corridor has equipment and metal storage racks located along one side of the 8' corridor, reducing its clear width in violation of 7.1.10.

Based on observation and interview with staff, the facility failed to provide anesthetizing locations protected in accordance with NFPA 99. Findings:

1) During the months including January, February, and March 2013, humidity levels were below 35%. No documentation of corrections to the humidity levels could be provided on the dates the humidity levels were out of the required range. Humidity levels should be recorded before each case.

Based on observation and interview with staff, the facility failed to provide latching hardware on doors protecting corridor openings. 18.3.6.3. Findings:


1) The double doors leading into the Surgery Suite do not have positive latching hardware.

Based on observation and interview with staff, the facility failed to provide smoke barriers that provide at least a one-hour fire resistance rating. Findings:

The smoke compartment wall (smoke barrier) does not meet the separation requirement at the following locations. (Note: these locations are not all-inclusive. The facility shall inspect all smoke barriers to determine additional unrated penetrations, etc.)

1) First Floor: An unrated corner exists in the wall between Surgery Holding 145 and G.I. Holding.

2) First Floor: An unrated metal support channel penetration exists in the wall between Trauma 1E07 and the adjacent corridor.

3) Second Floor: A square duct is not fire sealed above the door between the Atrium Lobby (Smoke Compartment 4) and the Vestibule (Smoke Compartment 3).

4) Second Floor: A square duct is not fire sealed over the double egress doors between Smoke Compartment 2 and Smoke Compartment 3.

5) Third Floor: Conduit is not fire sealed above the double egress doors between Smoke Compartment 1 and Smoke Compartment 3.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected by one hour fire rated construction. Findings:

1) Exam Room 1 (1K02 on floor plan sheet provided to surveyor) is now used as a Storage Room, is larger than 100 square feet, and is considered a hazardous area per Table 18.3.7.1 Hazardous Area Protection. This Storage Room is required to be protected by one-hour construction per 18.3.7.1.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system that is inspected periodically. Findings:

1) First Floor: Wires were found resting upon fire sprinkler piping at the east end of the corridor outside of Radiology, in violation of NFPA 25, 5.2.2.2

2) Third Floor Marketing Closet: The facility failed to provide 18" clear of obstructions below the sprinkler deflectors, in violation of NFPA 13, 5-5.5.3.

Based on observation and interview with staff, the facility failed to provide mean of egress continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency. Refer to 7.1.10. Findings.

1) The Surgery Suite Restricted Corridor has equipment and metal storage racks located along one side of the 8' corridor, reducing its clear width in violation of 7.1.10.

Based on observation and interview with staff, the facility failed to provide anesthetizing locations protected in accordance with NFPA 99. Findings:

1) During the months including January, February, and March 2013, humidity levels were below 35%. No documentation of corrections to the humidity levels could be provided on the dates the humidity levels were out of the required range. Humidity levels should be recorded before each case.