HospitalInspections.org

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that all structural steel maintained the spray on fire protection to provide for the proper fire rating.

During the validation survey at it was observed that the spray on fire protection was missing on structural steel at MR 641 Engineering.

An interview with staff members revealed that the facility was unaware of the spray on fire protection being missing.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Corridors are separated from use areas by walls constructed to resist the passage of smoke.

During the validation survey at it was observed that the following locations were not smoke tight.
A.)above ceiling at double doors in heritage hall area
B.)above ceiling at room 1350
C.)in file storage room for radiology
D.)room 1125
E.)above ceiling in area near room 1149
F.) ICU. Conference room has an unsealed penetration above ceiling next to door.
E.)4th floor Seal unprotected conduit above ceiling at NICU corridor doors.

An interview with Hospital staff members revealed that the facility was unaware that the areas were not smoke tight.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Doors protecting corridor openings are provided with a means suitable for keeping the door closed.

During the validation survey at it was observed that the following doors would not latch properly.
A). Room 4004
B). Room 4005

An interview with staff members revealed that the facility was unaware of that these doors were in need of adjustment to latch properly.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours.

During the validation survey at it was observed that unprotected verticle openings were present at the following locations.

A.) Room 7213, laundry chute rood damaged and held in an open position.
B.) On 5th Floor Seal conduit above ceiling next to east stairwell, above alarm strobe light.
C.) 6th Floor stairwell, make sure that the shower access panel is 2 hour rated.
D.) Unprotected vertical opening through Gift Shop storage room to the 2nd floor.

An interview with staff members revealed that the facility was unaware of the unprotected verticle openings.

During the tour of the facility conducted by Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that all hazardous areas were separated properly.

During the validation survey it was observed that the Changing room had been converted to a soiled linen room and the walls are not rated properly.

An interview with staff members revealed that the facility was unaware that the room was not properly separated.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that all hazardous areas were properly seperated.

During the validation survey at it was observed that the following rooms were not provided with self closing devices.

A). small storage room in Gift shop.
B). door to office 1222
C). Room 1211

An interview with staff members revealed that the facility was unaware of the need for door closers on these doors

During the validation survey at it was observed that there was damaged Sheetrock in linen closet next to room 7205, a hole exist at floor level on right hand side.

An interview with staff members revealed that the facility was unaware of the damage to the sheetrock.

During the validation survey at it was observed that Door 6027 will not latch properly.

An interview with staff members revealed that the facility was unaware that the latch was in need of adjustment to operate properly.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that emergency lighting was in proper operating condition.

During the validation survey it was observed that the emergency lighting unit in the second floor elevator lobby did not operate when tested.

An interview with staff members revealed that the facility was unaware the unit was inoperative.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that exit sign operated on emergency power.

During the validation survey at it was observed that the following exit signs did not operate when tested no emergency power:

Rooms 133, 175, 222
Second floor elevator lobby
Second floor at stairs

An interview with staff members revealed that the facility was unaware that the units were not operative on emergency power.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Fire alarm system met all requirements of NFPA 72.

During the validation survey at it was observed that the following areas were in need of the following to comply with NFPA 72.
A).Need additional smoke detectors installed at self closing doors at the Gift Shop
B). Heritage Hall area smoke detector not mounted properly.
C). smoke detector not mounted properly at smoke barrier at room 1235.
D).smoke detector not mounted properly in corridor at the Chapel.
E). Provide additional visual alarm devices in the Cashiers area due to partitions.

An interview with staff members revealed that the facility was unaware that the requirements of NFPA were not met.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that the sprinkler system covered all areas of the building.

During the validation survey it was observed that the following areas were not protected by the sprinkler system:

A) shower in Sleep Lab #3
B) shower in Sleep Lab #4
C) shower in Sleep Lab #5
D) shower in Sleep Lab #6
E) shower in Sleep Lab #8

An interview with Staff members revealed that the facility was unaware that these areas were not protected properly.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Required automatic sprinkler systems are continuously maintained in reliable operating condition.

During the validation survey at it was observed that the sprinkler system was not in compliance with NFPA13 in following areas:
A.)ground floor area A low voltage wiring tied off on sprinkler pipe
B.)ground floor area A hvac duct in contact with sprinkler piping
C.)gift shop storage room keep storage 18 inches below ceiling
D.)corridor at room 1328 sprinkler heads are spaced too far apart
E.)need protective cage on sprinkler heads in room 1634
F.)need protective cage on sprinkler heads in room 1250
G.)need protective cage on sprinkler heads in room 1224
H.)inadequate hangers on sprinkler pipe in the area of room 1250
I).provided sprinkler guards for sidewall head pharmacy alcove
J).room 1250 pharmacy dumbwaiter has large area without sprinkler coverage
K.)need proper sprinkler pipe hangers in pharmacy storage area
L.)room 1327 provide a upright sprinkler head instead of pennant that is there now
M).provide upright heads in MR 64 engineering area
N).wiring on sprinkler pipe radiology file storage
O).sprinkler head obstructed by duct radiology file storage
P).saddle tap in main not approved in radioogy file storage
Q.)provide proper sprinkler head wrench for spare sprinkler heads in all riser rooms
R.)ensure all sprinkler spare head boxes are mounted properly in all riser rooms
S).provided guards on sprinkler heads under duct in room 1024
T).a damaged sprinkler head was noted in the corridor outside room 1024
U.)wires lying on sprinkler piping medical records corridor
V.)stairs at elevator #9 west change sprinkler head to be upright sprinkler head
W.)need ceiling and sprinkler in small storage closet room 1235
X.)provided proper signage for all valves in room MR 20
Y).room 1105 improper sprinkler coverage additional heads may be required
Z).close ceiling and data closet room 6019
AA).improper sprinkler coverage room 1128 - heads too close to each other
BB).corridor at room 6019 appears to have too many heads on a 1 inch line and the density exceeds .15 for ordinary hazard group 1, lines too far apart should be 10 x 12 between heads.
CC).entry area at cashiers office using a piece of cardboard for sprinker pipe hanger
DD).duct for hvac on sprinkler pipe Sisters Conference room
EE.)sprinkler head at the atm is within 4 inches of the wall
FF).sprinkler pipe hanger missing for arm over at the atm
GG).no hanger on sprinkler pipe by room 1707 causing sprinkler head to drop below ceiling grid
HH).room 1708 horizontal arm over not provided with sprinkler hanger
II). patio dining area is 30 foot making sidewall heads not adequate for coverage
JJ). back side on outside dining area not provided with adequate sprinkler coverage
KK). provide proper signage for all FDC and PIV to identify system and area covered
LL). 6th Floor visitor elevator has non-approved sprinkler hanger, pipe is secured with wire
MM). NICU 4th floor environmental services closet check unknown substance on sprinkler hear, head is covered with an oily liquid.
NN). NICU 4th floor Sprinkler head at nursing station check unknown substance on sprinkler hear, head is covered with an oily liquid.
OO). Storage was noted above the limited area to be covered by the sprinkler system.


An interview with staff members revealed that the facility was unaware of that the sprinkler system was not incompliance with NFPA 13 in these areas.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that all protable fire extinguishers met the requirements of NFPA 10.

During the validation survey at it was observed that the following items did not meet the requirements of NFPA 10:

A). room 1211 extinguisher provided does not meet the requirements for a BC type extinguisher called for due to the hazard it is to cover.
B). room MR20 extinguisher has a non-approved 6 year service collar.


An interview with staff members revealed that the facility was unaware of the extinguishers not meeting the requirements of NFPA 10.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that all HVAC systems were installed properly.

During the validation survey at it was observed that the Fire Damper in Room 3311 has been cut so that conduit could be installed.

An interview with staff members revealed that the facility was unaware that the damper had been cut.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Cooking facilities were in accordance with NFPA 96.

During the validation survey at it was observed that the Hood Fire Supression System in the ADL kitchen is past due semi-annual service.

An interview with staff members revealed that the facility was unaware that the system was past due the service date.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that no portable space heaters were in use that did not meet the limits of the heating elements.

During the validation survey at it was observed that there was a portable space heater in use in room 1242.

An interview with staff members revealed that the facility was unaware of the heater being in the facility.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Medical gas storage was in accordance with NFPA 99.

During the validation survey at it was observed that the nitrogen cylinder in Room 2711was not secured properly.

An interview with staff members revealed that the facility was unaware that the cylinder was not secured.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that the State requirement that all rated walls be labeled properly was met.

During the validation survey at it was observed that the rated walls throughout the facility were in need of being labeled to reflect the rating of the wall. In some areas the walls are no longer used as a rated wall and the labeling needs to be covered or removed. All elevator shafts need to be labeled inside and outside the shaft wall.

An interview with staff members revealed that the facility was unaware of the need to update the labeling of the walls.


During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that the requirements for use of a Clean Agent Fire Supression SYtem were followed.

During the validation survey at it was observed that the Clean Agent Fire supression system in room 1307 was not provided 36 inches of clear space around the electrical control unit.

During the validation survey at it was observed that the Clean Agent Fire supression system in room 1307 was not provided with required signage warnining of the harmful Halon enviroment in the case of system discharge.

An interview with staff members revealed that the facility was unaware of these requirements.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Electrical wiring was in accordance with NFPA 70, National Electrical Code

During the validation survey at it was observed that there were extension cords used as permanent wiring throughout the facility

An interview with staff members revealed that the facility was unaware of the extension cords being used.

During the validation survey at it was observed that there power strips in use through out the facility that were not mounted to protect them from physical harm.

An interview with staff members revealed that the facility was unaware of the requirement that these strips be mounted.

During the validation survey at it was observed that there was a power strip in room 1211 that was over loaded. The strip had a coffee pot, toaster oven, and a micro-wave oven pluged into it.

An interview with staff members revealed that the facility was unaware of this condition.

During the validation survey at it was observed that there were open junction boxes at the following locations.

A). above ceiling at room 1634
B). Ground floor elevator shaft B

An interview with staff members revealed that the facility was unaware of the open junction boxes.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that the requirements for use of Alcohol Based Hand Rub dispensers were met.

During the validation survey at it was observed that Alcohol Based Hand Rub dispensers were mounted above or too close to electrical recepticles throughout the facility.

An interview with staff members revealed that the facility was unaware that these units were not placed properly.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that all structural steel maintained the spray on fire protection to provide for the proper fire rating.

During the validation survey at it was observed that the spray on fire protection was missing on structural steel at MR 641 Engineering.

An interview with staff members revealed that the facility was unaware of the spray on fire protection being missing.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Corridors are separated from use areas by walls constructed to resist the passage of smoke.

During the validation survey at it was observed that the following locations were not smoke tight.
A.)above ceiling at double doors in heritage hall area
B.)above ceiling at room 1350
C.)in file storage room for radiology
D.)room 1125
E.)above ceiling in area near room 1149
F.) ICU. Conference room has an unsealed penetration above ceiling next to door.
E.)4th floor Seal unprotected conduit above ceiling at NICU corridor doors.

An interview with Hospital staff members revealed that the facility was unaware that the areas were not smoke tight.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Doors protecting corridor openings are provided with a means suitable for keeping the door closed.

During the validation survey at it was observed that the following doors would not latch properly.
A). Room 4004
B). Room 4005

An interview with staff members revealed that the facility was unaware of that these doors were in need of adjustment to latch properly.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours.

During the validation survey at it was observed that unprotected verticle openings were present at the following locations.

A.) Room 7213, laundry chute rood damaged and held in an open position.
B.) On 5th Floor Seal conduit above ceiling next to east stairwell, above alarm strobe light.
C.) 6th Floor stairwell, make sure that the shower access panel is 2 hour rated.
D.) Unprotected vertical opening through Gift Shop storage room to the 2nd floor.

An interview with staff members revealed that the facility was unaware of the unprotected verticle openings.

During the tour of the facility conducted by Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that all hazardous areas were separated properly.

During the validation survey it was observed that the Changing room had been converted to a soiled linen room and the walls are not rated properly.

An interview with staff members revealed that the facility was unaware that the room was not properly separated.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that all hazardous areas were properly seperated.

During the validation survey at it was observed that the following rooms were not provided with self closing devices.

A). small storage room in Gift shop.
B). door to office 1222
C). Room 1211

An interview with staff members revealed that the facility was unaware of the need for door closers on these doors

During the validation survey at it was observed that there was damaged Sheetrock in linen closet next to room 7205, a hole exist at floor level on right hand side.

An interview with staff members revealed that the facility was unaware of the damage to the sheetrock.

During the validation survey at it was observed that Door 6027 will not latch properly.

An interview with staff members revealed that the facility was unaware that the latch was in need of adjustment to operate properly.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that emergency lighting was in proper operating condition.

During the validation survey it was observed that the emergency lighting unit in the second floor elevator lobby did not operate when tested.

An interview with staff members revealed that the facility was unaware the unit was inoperative.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that exit sign operated on emergency power.

During the validation survey at it was observed that the following exit signs did not operate when tested no emergency power:

Rooms 133, 175, 222
Second floor elevator lobby
Second floor at stairs

An interview with staff members revealed that the facility was unaware that the units were not operative on emergency power.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Fire alarm system met all requirements of NFPA 72.

During the validation survey at it was observed that the following areas were in need of the following to comply with NFPA 72.
A).Need additional smoke detectors installed at self closing doors at the Gift Shop
B). Heritage Hall area smoke detector not mounted properly.
C). smoke detector not mounted properly at smoke barrier at room 1235.
D).smoke detector not mounted properly in corridor at the Chapel.
E). Provide additional visual alarm devices in the Cashiers area due to partitions.

An interview with staff members revealed that the facility was unaware that the requirements of NFPA were not met.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that the sprinkler system covered all areas of the building.

During the validation survey it was observed that the following areas were not protected by the sprinkler system:

A) shower in Sleep Lab #3
B) shower in Sleep Lab #4
C) shower in Sleep Lab #5
D) shower in Sleep Lab #6
E) shower in Sleep Lab #8

An interview with Staff members revealed that the facility was unaware that these areas were not protected properly.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Required automatic sprinkler systems are continuously maintained in reliable operating condition.

During the validation survey at it was observed that the sprinkler system was not in compliance with NFPA13 in following areas:
A.)ground floor area A low voltage wiring tied off on sprinkler pipe
B.)ground floor area A hvac duct in contact with sprinkler piping
C.)gift shop storage room keep storage 18 inches below ceiling
D.)corridor at room 1328 sprinkler heads are spaced too far apart
E.)need protective cage on sprinkler heads in room 1634
F.)need protective cage on sprinkler heads in room 1250
G.)need protective cage on sprinkler heads in room 1224
H.)inadequate hangers on sprinkler pipe in the area of room 1250
I).provided sprinkler guards for sidewall head pharmacy alcove
J).room 1250 pharmacy dumbwaiter has large area without sprinkler coverage
K.)need proper sprinkler pipe hangers in pharmacy storage area
L.)room 1327 provide a upright sprinkler head instead of pennant that is there now
M).provide upright heads in MR 64 engineering area
N).wiring on sprinkler pipe radiology file storage
O).sprinkler head obstructed by duct radiology file storage
P).saddle tap in main not approved in radioogy file storage
Q.)provide proper sprinkler head wrench for spare sprinkler heads in all riser rooms
R.)ensure all sprinkler spare head boxes are mounted properly in all riser rooms
S).provided guards on sprinkler heads under duct in room 1024
T).a damaged sprinkler head was noted in the corridor outside room 1024
U.)wires lying on sprinkler piping medical records corridor
V.)stairs at elevator #9 west change sprinkler head to be upright sprinkler head
W.)need ceiling and sprinkler in small storage closet room 1235
X.)provided proper signage for all valves in room MR 20
Y).room 1105 improper sprinkler coverage additional heads may be required
Z).close ceiling and data closet room 6019
AA).improper sprinkler coverage room 1128 - heads too close to each other
BB).corridor at room 6019 appears to have too many heads on a 1 inch line and the density exceeds .15 for ordinary hazard group 1, lines too far apart should be 10 x 12 between heads.
CC).entry area at cashiers office using a piece of cardboard for sprinker pipe hanger
DD).duct for hvac on sprinkler pipe Sisters Conference room
EE.)sprinkler head at the atm is within 4 inches of the wall
FF).sprinkler pipe hanger missing for arm over at the atm
GG).no hanger on sprinkler pipe by room 1707 causing sprinkler head to drop below ceiling grid
HH).room 1708 horizontal arm over not provided with sprinkler hanger
II). patio dining area is 30 foot making sidewall heads not adequate for coverage
JJ). back side on outside dining area not provided with adequate sprinkler coverage
KK). provide proper signage for all FDC and PIV to identify system and area covered
LL). 6th Floor visitor elevator has non-approved sprinkler hanger, pipe is secured with wire
MM). NICU 4th floor environmental services closet check unknown substance on sprinkler hear, head is covered with an oily liquid.
NN). NICU 4th floor Sprinkler head at nursing station check unknown substance on sprinkler hear, head is covered with an oily liquid.
OO). Storage was noted above the limited area to be covered by the sprinkler system.


An interview with staff members revealed that the facility was unaware of that the sprinkler system was not incompliance with NFPA 13 in these areas.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that all protable fire extinguishers met the requirements of NFPA 10.

During the validation survey at it was observed that the following items did not meet the requirements of NFPA 10:

A). room 1211 extinguisher provided does not meet the requirements for a BC type extinguisher called for due to the hazard it is to cover.
B). room MR20 extinguisher has a non-approved 6 year service collar.


An interview with staff members revealed that the facility was unaware of the extinguishers not meeting the requirements of NFPA 10.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that all HVAC systems were installed properly.

During the validation survey at it was observed that the Fire Damper in Room 3311 has been cut so that conduit could be installed.

An interview with staff members revealed that the facility was unaware that the damper had been cut.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Cooking facilities were in accordance with NFPA 96.

During the validation survey at it was observed that the Hood Fire Supression System in the ADL kitchen is past due semi-annual service.

An interview with staff members revealed that the facility was unaware that the system was past due the service date.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that no portable space heaters were in use that did not meet the limits of the heating elements.

During the validation survey at it was observed that there was a portable space heater in use in room 1242.

An interview with staff members revealed that the facility was unaware of the heater being in the facility.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Medical gas storage was in accordance with NFPA 99.

During the validation survey at it was observed that the nitrogen cylinder in Room 2711was not secured properly.

An interview with staff members revealed that the facility was unaware that the cylinder was not secured.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that the State requirement that all rated walls be labeled properly was met.

During the validation survey at it was observed that the rated walls throughout the facility were in need of being labeled to reflect the rating of the wall. In some areas the walls are no longer used as a rated wall and the labeling needs to be covered or removed. All elevator shafts need to be labeled inside and outside the shaft wall.

An interview with staff members revealed that the facility was unaware of the need to update the labeling of the walls.


During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that the requirements for use of a Clean Agent Fire Supression SYtem were followed.

During the validation survey at it was observed that the Clean Agent Fire supression system in room 1307 was not provided 36 inches of clear space around the electrical control unit.

During the validation survey at it was observed that the Clean Agent Fire supression system in room 1307 was not provided with required signage warnining of the harmful Halon enviroment in the case of system discharge.

An interview with staff members revealed that the facility was unaware of these requirements.

During the tour of the facility conducted by the Life Safety Code Team accompanied by members of the Hospital staff it was noted that the facility failed to ensure that Electrical wiring was in accordance with NFPA 70, National Electrical Code

During the validation survey at it was observed that there were extension cords used as permanent wiring throughout the facility

An interview with staff members revealed that the facility was unaware of the extension cords being used.

During the validation survey at it was observed that there power strips in use through out the facility that were not mounted to protect them from physical harm.

An interview with staff members revealed that the facility was unaware of the requirement that these strips be mounted.

During the validation survey at it was observed that there was a power strip in room 1211 that was over loaded. The strip had a coffee pot, toaster oven, and a micro-wave oven pluged into it.

An interview with staff members revealed that the facility was unaware of this condition.

During the validation survey at it was observed that there were open junction boxes at the following locations.

A). above ceiling at room 1634
B). Ground floor elevator shaft B

An interview with staff members revealed that the facility was unaware of the open junction boxes.