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Based on observations the facility failed to provide the required 1- hour fire rated construction for vertical openings in facility five (5) stories in height.

Any vertical opening shall be enclosed or protected with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Where enclosures are provided, the construction shall have not less than 1-hour fire resistance rating. 19.3.1.1, 8.2.5

Findings include:

While inspecting shafts and stairways on January 24 through January 26, 2011 the surveyor observed the East, West, and Central Service Elevator shafts with unsealed penetrations throughout.

While inspecting the main mechanical shaft next to the central service elevator on January 25, 2011. The surveyor observed non-rated access panels in the shaft extending from the basement through 5th floor.

While inspecting the nursery mechanical shaft that extends from the basement to the 5th floor on January 26, 2011. The surveyor observed the shaft being construction with only one layer of 5/8 in sheet rock and exposed studs.

While inspecting the pipe hall located in the basement on January 26, 2011. The survey observed an unsealed vertical opening (unsealed expansion joint) extending from the basement to the 1st floor.

These deficient practices have the potential of affecting the basement through 5th floor. The maintenance director and administrator were notified during the survey as well as in the exit conference.

Based on observation the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in an existing fully sprinkled facility.

Smoke barriers shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier. Any required smoke barrier shall be constructed with a minimum of 30 minute fire resistance rating 19.3.7.3, 8.3.

Findings include:

While inspecting smoke barrier walls on January 24 through January 26, 2011 the surveyor observed the following smoke barrier walls with unsealed penetrations throughout.

1. ICU / CCU smoke wall located on the 1st floor.
2. Lab / Day surgery smoke wall located on the 1st floor.
3. O.B / LDR smoke barrier wall located on the 1st floor.
4. Father waiting area / LDR smoke barrier wall located on the 1st floor.
5. Cath Lab Recovery smoke barrier wall located in the basement.
6. Medical Records smoke barrier wall located in the basement.
7. Neurology smoke barrier wall located in the basement.

These deficient practices have the potential of affecting the basement and 1st floor of a 5 story building. The maintenance director and administrator were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required fire rated or wired glass in a smoke barrier door vision panel.

Openings in smoke barrier doors shall be protected by fire-rated glazing; wired glass panels and steel frames 19.3.7.5.

Findings include:

On January 26, 2011 at 3:00 p.m., the surveyor observed non-rated glass located in the fathers waiting area / Nursery smoke barrier doors located on the 1st floor.

These deficient practices have the potential of affecting 2 smoke compartments on the 1st floor. The maintenance director and administrator were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required smoke resistive partitons and doors in rooms protected by an automatic sprinkler system and designated as a hazardous area.

Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided one hour fire rated construction protected by a forty-five minute, fire-rated, door attached with self closing hardware, 19.3.2.1, or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. On January 24 through January 26, 2011 the surveyor observed the following sprinkler protected hazardous areas which would not resist the passage of smoke.

1. Medical records storage located in the basement was observed with unfinished construction (perimeter rated walls not extending to the deck above) room is incapable of resisting the passage of smoke.
2. Medical records supply room located in the basement was observed with unsealed penetrations throughout perimeter rated walls. Room is incapable of resisting the passage of smoke.
3. Medical records supply room located in the basement was observed without the required self closing hardware on the door assembly.
4. Medical records elevator equipment room located in the basement was observed without the required self closing hardware on the door assembly.
5. Neurology storage #2 located in the basement was observed without the required self closing hardware in the door assembly.
6. Neurology storage #1 at sleep lab located in the basement was observed without the required self closing hardware in the door assembly.
7. Sleep lab storage located in the basement was observed without the required self closing hardware in the door assembly.
8. Back hall cath lab soiled linen room located in basement was observed with unsealed penetrations throughout. Room was incapable of resisting the passage of smoke.
9. Cath lab soiled linen room located in the basement was observed without, self closing hardware on the fire door assembly.
10. 1st floor lab soiled utility/soiled trash room was observed without self closing hardware on the door assembly.
11. 1st floor ICU soiled utility/soiled linen room was observed without the required self closing hardware on the door assembly.
12. Nursery electrical/transformer/storage room located in the 1st floor was observed without one-hour rated construction (walls did not extend to deck), forty five minute fire rated doors, or self closing hardware. Multiple transformers were located in this unrated electrical room. Room was incapable of resisting the passage of smoke. NFPA 70, National Electrical Code, Section 450-21(a) and (b).
13. Nursery soiled linen/utility/bio-hazard room located on the 1st floor was observed without self closing hardware on the door assembly.
14. LDR storage room located on the 1st floor was observed without the required self closing hardware in the door assembly.
15. LDR soiled linen/bio-hazard room located on 1st floor across from room 177 was observed without self closing hardware on the door assembly.
16. LDR triage soiled linen/bio-hazard room located on 1st floor was observed without self closing hardware on door assembly.
These deficient practices have the potential of affecting the entire basement and 1st floor. The maintenance director and administrator were notified during the survey as well as in the exit conference.

Based on observations the facility failed to install and maintain electrical wiring in accordance with NFPA 70, National Electrical Code.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions used. NFPA 70, National Electrical Code, Section 370-28 (c).

Findings include:

While inspecting electrical wiring on January 24 through January 26, 2011 the surveyor observed unsealed or uncovered junction boxes in every hallway throughout the building extending from the basement to the 5th floor.

These deficient practices have the potential of affecting the entire facility. The maintenance director and administrator were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required 1- hour fire rated construction for vertical openings in facility five (5) stories in height.

Any vertical opening shall be enclosed or protected with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Where enclosures are provided, the construction shall have not less than 1-hour fire resistance rating. 19.3.1.1, 8.2.5

Findings include:

While inspecting shafts and stairways on January 24 through January 26, 2011 the surveyor observed the East, West, and Central Service Elevator shafts with unsealed penetrations throughout.

While inspecting the main mechanical shaft next to the central service elevator on January 25, 2011. The surveyor observed non-rated access panels in the shaft extending from the basement through 5th floor.

While inspecting the nursery mechanical shaft that extends from the basement to the 5th floor on January 26, 2011. The surveyor observed the shaft being construction with only one layer of 5/8 in sheet rock and exposed studs.

While inspecting the pipe hall located in the basement on January 26, 2011. The survey observed an unsealed vertical opening (unsealed expansion joint) extending from the basement to the 1st floor.

These deficient practices have the potential of affecting the basement through 5th floor. The maintenance director and administrator were notified during the survey as well as in the exit conference.

Based on observation the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in an existing fully sprinkled facility.

Smoke barriers shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier. Any required smoke barrier shall be constructed with a minimum of 30 minute fire resistance rating 19.3.7.3, 8.3.

Findings include:

While inspecting smoke barrier walls on January 24 through January 26, 2011 the surveyor observed the following smoke barrier walls with unsealed penetrations throughout.

1. ICU / CCU smoke wall located on the 1st floor.
2. Lab / Day surgery smoke wall located on the 1st floor.
3. O.B / LDR smoke barrier wall located on the 1st floor.
4. Father waiting area / LDR smoke barrier wall located on the 1st floor.
5. Cath Lab Recovery smoke barrier wall located in the basement.
6. Medical Records smoke barrier wall located in the basement.
7. Neurology smoke barrier wall located in the basement.

These deficient practices have the potential of affecting the basement and 1st floor of a 5 story building. The maintenance director and administrator were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required fire rated or wired glass in a smoke barrier door vision panel.

Openings in smoke barrier doors shall be protected by fire-rated glazing; wired glass panels and steel frames 19.3.7.5.

Findings include:

On January 26, 2011 at 3:00 p.m., the surveyor observed non-rated glass located in the fathers waiting area / Nursery smoke barrier doors located on the 1st floor.

These deficient practices have the potential of affecting 2 smoke compartments on the 1st floor. The maintenance director and administrator were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required smoke resistive partitons and doors in rooms protected by an automatic sprinkler system and designated as a hazardous area.

Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided one hour fire rated construction protected by a forty-five minute, fire-rated, door attached with self closing hardware, 19.3.2.1, or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. On January 24 through January 26, 2011 the surveyor observed the following sprinkler protected hazardous areas which would not resist the passage of smoke.

1. Medical records storage located in the basement was observed with unfinished construction (perimeter rated walls not extending to the deck above) room is incapable of resisting the passage of smoke.
2. Medical records supply room located in the basement was observed with unsealed penetrations throughout perimeter rated walls. Room is incapable of resisting the passage of smoke.
3. Medical records supply room located in the basement was observed without the required self closing hardware on the door assembly.
4. Medical records elevator equipment room located in the basement was observed without the required self closing hardware on the door assembly.
5. Neurology storage #2 located in the basement was observed without the required self closing hardware in the door assembly.
6. Neurology storage #1 at sleep lab located in the basement was observed without the required self closing hardware in the door assembly.
7. Sleep lab storage located in the basement was observed without the required self closing hardware in the door assembly.
8. Back hall cath lab soiled linen room located in basement was observed with unsealed penetrations throughout. Room was incapable of resisting the passage of smoke.
9. Cath lab soiled linen room located in the basement was observed without, self closing hardware on the fire door assembly.
10. 1st floor lab soiled utility/soiled trash room was observed without self closing hardware on the door assembly.
11. 1st floor ICU soiled utility/soiled linen room was observed without the required self closing hardware on the door assembly.
12. Nursery electrical/transformer/storage room located in the 1st floor was observed without one-hour rated construction (walls did not extend to deck), forty five minute fire rated doors, or self closing hardware. Multiple transformers were located in this unrated electrical room. Room was incapable of resisting the passage of smoke. NFPA 70, National Electrical Code, Section 450-21(a) and (b).
13. Nursery soiled linen/utility/bio-hazard room located on the 1st floor was observed without self closing hardware on the door assembly.
14. LDR storage room located on the 1st floor was observed without the required self closing hardware in the door assembly.
15. LDR soiled linen/bio-hazard room located on 1st floor across from room 177 was observed without self closing hardware on the door assembly.
16. LDR triage soiled linen/bio-hazard room located on 1st floor was observed without self closing hardware on door assembly.
These deficient practices have the potential of affecting the entire basement and 1st floor. The maintenance director and administrator were notified during the survey as well as in the exit conference.

Based on observations the facility failed to install and maintain electrical wiring in accordance with NFPA 70, National Electrical Code.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions used. NFPA 70, National Electrical Code, Section 370-28 (c).

Findings include:

While inspecting electrical wiring on January 24 through January 26, 2011 the surveyor observed unsealed or uncovered junction boxes in every hallway throughout the building extending from the basement to the 5th floor.

These deficient practices have the potential of affecting the entire facility. The maintenance director and administrator were notified during the survey as well as in the exit conference.