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From random observation during the survey walk through, the surveyor accompanied by the Director of Facilities and the Head of Maintenance, finds that use areas are not separated from exit access corridors to comply with 19-3.6.1. This condition may expose patients, staff and visitors to a fire emergency because the lack of smoke detectors could result in delayed activation of the fire alarm system compromising the facility's exit access corridors.

Findings include:

A. The morning of 2/07/2012, The 9th Floor -GI Unit (non sprinklered floor) Reception Area and Waiting Area which are not manned 24 hours, were observed to be open to the Corridor, the areas were observed to lack a smoke detector in accord with exception 6. [subpart(a)] to 19.3.6.1.


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B. CORRECTED 08/09/12

Based on observations it was determined that the facility failed to maintain the closure for corridor doors in accordance with UL tested design assemblies and NFPA 101, 19.3.6.3.2. Findings include:

1. 2nd floor, recovery room doors do not contain latching hardware to the exit corridor.




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B. The 1st floor Cafeteria corridor doors do not have functional latching hardware to comply with 19.3.6.3.2.

C. The 1st floor Radiaology room #3 corridor door does not have functional latching hardware to comply with 19.3.6.3.2.

D. The 1st floor corridor doors at the Emergency Dept. are equipped with power operators. The power operator function did not cease to function under fire alarm activation to comply with 7.2.1.9.1.

E. The 1st floor corridor doors at the Ambulatory Services suite are not coordinated to close properly. Upon activation of the fire alarm or when once closed and reopened, the astragal door prevented the doors from being able to latch.

F. The 2nd floor pair of doors from the designated Surgery suite are equipped with magnetic locking devices in lieu of positive latching hardware. These doors are also designated to form an a 1-hour separation of the 2-story Lobby space from the remainder of the building but lack the required fire rating labels. See K20 also.
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From random observations, the surveyors accompanied by the Director of Facilities and the Head of Maintenance find that the facility failed to maintain the closure for corridor doors to comply with 19.3.6.3.2. This condition may expose patients, staff and visitors to a fire emergency within the exit access corridor and impede movement to an exit discharge.

Findings include:

A. CORRECTED 08/09/12
B. CORRECTED 08/09/12


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C The afternoon of 2/08/2012, corridor doors contain manual hold open devices.
1. First Floor O.R. doors
2. First Floor Recovery doors leading to corridor between the Recovery suite and the O.R. suite
3. Third Floor, Chapel corridor doors contain foot pegs.

D. The afternoon of 2/08/2012, First Floor, ICU North pair of cross corridor doors do not latch, these doors are not indicated to be part of a smoke barrier.

Based on random observation during the survey walk-through, not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. Findings include:

1. 4th floor Toilet room located in dialysis contains a small opening into a shaft and the access door was not rated. The opening was too small to determine the number of floors that were served by this shaft, or the rating of the shaft itself.




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B. The 6th, 7th, and 8th floors are currently being gutted and reconstructed as non-healthcare occupancies. The 5th floor and 9th floors remain healthcare occupancy with patient sleeping rooms. The demolition/construction process has exposed or created floor openings and/or unenclosed shafts between all the above 5th thru 9th floors and other floors of the building in non-compliance with 19.3.1.1 and 8.2.5. Interim Life Safety Measures (ILSM) are deemed inadequate for the protection of the patient populations on the adjacent floors to the construction for the following reasons:

1. ILSM Fire Watch surveillance inspections are conducted only by contractor personnel and only during day shift periods when construction is actively taking place. No hazard surveillance is conducted durng non-work periods. The time of day for the hazard surveillance inspection was not identified to determine whether inspections took place at the end of the work day prior to leaving the areas unattended.

2. ILSM report documentation indicates unobstructed exits and functional fire alarm system components. As observed on the day of the survey, two of the three exits from the floors were not available due to construction barriers or dust control barriers. The only available exit was an exterior fire escape stair located at the far north end of the floor. The fire alarm system had been removed except for a single horn and a single pull station. This avaialble pull station was hidden by construction materials and was located at the center stair which was not available for use.

C. Large unsealed conduits located in the 1st floor Pavilion building Tech Equipment room near Electric room 15170 where not confirmed to communicate to other floors.

D. It is not clear how the 2-story Lobby area of the Pavilion building complies with 8.2.5. The following was observed:

1. The door at the 2nd floor Behaviorial Health area is located in a designated 1-hour wall and is equipped with an electric strike indicated to be on a time clock which did not provide latching at the time of the survey walk-thru.

2. The pair of doors at the 2nd floor which access the designated Surgical suite area are located in a designated 1-hour wall and provided with magnetic locking devices in lieu of positive latching hardware. See K18 also. These doors are not labeled as having a fire resistance rating to separate the 2-story space from other areas similar to other doors in the 1-hour rated walls.

3. The 1st floor contains an elevator with two-sided openings which breeches the 1-hour barrier relative to the movement of smoke.

4. The 2nd floor corridor/elevator lobby is provided with only a single exit to a stair in non-compliance with 19.2.4.1 and 7.5.

E. The Center Elevator Penthouse has a steel plate floor hatch which could not be confirmed to be of fire rated construction to maintain separation from the 11th floor below.
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From random observation during the survey walk through, the surveyors accompanied by the Director of Facilities and the Head of Maintenance find that vertical openings are not enclosed comply with 8.2.5.3 and 19.3.1.1. Unenclosed shafts may affect patient care areas on several floors and smoke compartments, preventing the safe movement of patients, visitors and staff during a fire emergency.

Findings include:

A. The morning of 02/07/2012, Seventh Floor Med/Surg: A duct penetration through the shaft wall across Room 734 and Room 735 was observed that is not equipped with a fire damper to comply with 8.2.3.2.4.1. and NFPA 90A 1999 3-3.2

B. The morning of 02/07/2012, Seventh Floor Med/Surg: The surveyor observed the integrity of the shaft wall located in the Soiled Holding Room 749 is compromised due to ductwork which is partially exposed and laying on top of the shaft.



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C. Shafts are open to the ceiling cavity's of adjacent spaces which is not permitted by NFPA 90A 3-3.2. These shafts extend up for an unknown height. These rooms constitute part of the shaft which does not comply with NFPA 101 8.2.5.3. Example locations observed:

1. CORRECTED 08/09/12
2. The afternoon of 2/6/12 at the 17 th floor mechanical room an unenclosed duct shaft for E.F. #4 was observed. The shaft penetration at the floor is covered with sheet metal which lacks a fire rating.

3. The morning of 2/6/2012, 17 th floor mechanical room contains an unenclosed duct shaft for E.F. #3. The shaft penetration at the floor contains a continuous gap without any type of fire stopping.


D. CORRECTED 08/09/12
E. The afternoon of 02/07/2012, The Atrium could not be verified as being in compliance with 8.2.5.6. for the reasons described below:

1. During an interview held on the afternoon of 2/7/2012, the provider's Director of Facilities was not able to verify that an engineering analysis, required by 9.2.5.6(5) had been performed with respect to the Atrium.

2. During an interview held on the afternoon of 2/7/2012 , the provider's Director of Facilities confirmed that the remainder of the building is not completely sprinkler protected to comply with 8.2.5.6 (4). It was determined through random observation that the ninth floor is not sprinkler protected.

Based on random observation during the survey walk-through, not all doors required to be self-closing are in compliance with 7.2.1.8.1. This deficiency could affect all patients within the smoke compartment, as well as any staff and visitors present, by allowing the products of combustion to pass from one side of the door to the other; either compromising the building's exit access corridors or the rooms occupied or adjacent to the space designed to be separated.

Finding include:
A. The Lower Level Resale shop is deemed a hazardous area due to the storage of combustible materials. The corridor door equipped with a closer was observed to be held open by a wedge where compliance with 19.3.2.1 and 8.4.1 was not maintained.

B. The door at the top of the stair accessing the Radiology File room at the lower level was observed to be propped open by wedging the door with paper towels. Compliance with 8.2.5.7 was not maintained.
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From random observation during the survey walk through, the surveyors accompanied by the Head of Maintenance and the Director of Facility's, finds that fire doors and/or smoke doors are not installed to close automatically from activation of the fire alarm and sprinkler system to comply with 19.2.2.2.6. 7.2.1.8 and NFPA 72. Failure to close fire doors in accordance with NFPA 101 could allow the spread of fire and smoke throughout floor levels of the building and affect the egress of patients, staff and visitors.

Findings include:

A. The morning of 2/08/2012, Tenth Floor ( Telemetry) Double Doors within the fire barriers by the Nurse Station were observed which failed to close and latch upon activation of the fire alarm in accordance with 7.2.1.8.2.


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B. The morning of 2/08/2012 Lower Level pair of 3-hour rated sliding corridor doors to Receiving, which includes other hazardous areas such as the Loading Dock and Surgery storage, operate manually and are held in the open position. These doors do not close by activation of the fire alarm system or by local smoke detection.
UPDATE 08/09/12 - Vendor supplied hardware and door remain on order, awaiting material delivery.

Based on observations it was determined that the facility failed to maintain the facility smoke barrier and/or doors in accordance with NFPA 101, 19.3.7 and 8.3.

Findings include:
A. 2nd floor, smoke barrier wall on North End of floor between the waiting room and the Directors office, a duct was observed located along the top of the wall. The wall is not sealed along the top of the duct to the deck above. The duct has no fire rating to meet the minimum ½ hour rating in accordance with NFPA 101, 19.3.7.3.

B. 2nd floor, smoke barrier located South of center, the cross-corridor smoke barrier doors equipped with auto openers failed to cease to function during the activation of the fire alarm system. To comply with NFPA 101, 7.2.1.9.2.

C. 3rd floor, smoke barrier wall located on the North End of floor. Clean utility room unsealed duct and conduit penetrations were observed.

D. 9th floor smoke barrier cross-corridor doors were propped open utilizing paper towels wedged under the doors. The doors were not self closing to comply with NFPA 101, 19.3.7.6. and failed to close during the activation of the fire alarm system.


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E. The 3rd floor east door in the south smoke barrier failed to close completely upon activation of the fire alarm system due to friction obstructing the door.
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A. Based on observation and staff interview, the facility failed to provide 1 hour rated separation including ¾ hour rated self closing doors, and hardware to provide separation between hazardous areas and other areas that are not otherwise sprinkled in accordance with the requirements of NFPA 101, 2000 Edition, Section 19.3.2.1.

Findings include:
1. 4th floor, ICU-7, is greater than 50 square feet and is not sprinkler protected or separated by one hour rated construction and was being used for storage and is considered to be a hazardous area.

2. 2nd floor rooms 2S24, 2S26, 2S28 and 2S30 are rooms greater than 50 square feet and is not sprinkler protected or separated by one hour rated construction and was being used for storage and is considered to be a hazardous area.

3. 2nd floor OR #6, is a room greater than 50 square feet and is not sprinkler protected or separated by one hour rated construction and was being used for storage and is considered to be a hazardous area.

4. 2nd floor OR#1, is a room greater than 50 square feet and is not sprinkler protected or separated by one hour rated construction and was being used for storage and is considered to be a hazardous area.


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B. Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors in the event of a fire condition.

Findings include:
1. The storage room at the north end of the Lower Level appears larger than 50 square feet and is not sprinkler protected or otherwise provided with 1-hour rated separation.

2. The east pair of doors of the Lower Level Resale Shop Storage room are not self-closing to a latched condition.

3. The Lower Level Housekeeping Dept. corridor door BS04 is not self-closing to a latched condition.

4. The 1st floor north end east side construction area is not separted from the corridor/exit passageway by fire rated construction to comply with 19.3.2.1 and 7.2.6. One-half of the double egress door has been removed and replaced with a plywood panel. The remaining door does not latch.

5. The 1st floor north end west side construction area is not separted from the corridor by fire rated construction to comply with 19.3.2.1 and 8.4.1. The gutted area is open to the adjacent occuppied areas above ceiling space. The temporary corridor door is not fire rated construction.

6. The 1st floor Radiology File Storage room corridor door was observed to have the door closer disconnected.
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From random observation during the survey walk through, the surveyor accompanied by the Director of Facility's finds that not all hazardous areas are separated from the remainder of the building to comply with 19.3.2.1. The hazardous areas covered by a sprinkler system were observed that are not separated from exit egress corridors. This condition may prevent staff and visitors within the means of egress against safe passage to an exit discharge.

Findings include:

A. Doors to hazardous rooms were observed that do not carry a minimum 3/4 hour fire resistance rating to comply with 19.3.2.1. and 8.2.3.2.3.1(2). Locations observed include:
1. The morning of 02/07/2012: Ninth Floor (Non Sprinklered), Storage Supply Room.
B. The morning of 02/07/2012: Ninth Floor the door to the Housekeeping Closet and was observed to not be self-closing to comply with 19.3.2.1. and 8.2.3.2.3.1(1).

C. Non sprinklered hazardous rooms were observed that are not enclosed by one hour fire rated walls to comply with 19.3.2.1. Locations observed include:

1. The morning of 02/07/2012: Ninth Floor: Designated Storage Rooms over 100 sq. ft. on this floor are not separated by one hour walls from other areas to comply with 19.3.2.1. Locations observed include:

a. Old patient rooms are being used for Storage Rooms.

b. G.I. Endoscopy Storage Supply Room is not separated.

D. Door to hazardous room (sprinklered area) was observed that is not self-closing to comply with 19.3.2.1. and 8.2.3.2.3.1(2). Locations observed include:
1. The afternoon of 02/07/2012: 8th Floor (Sprinklered Area), Janitor's Closet door is not self-closing.

E. The afternoon of 02/07/2012 Sixth Floor- The Soiled Holding Room across the Elevator Lobby T6037 was observed with an open hole that is not sealed against fire to comply with 8.2.3.2.4.2.


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F. CORRECTED 08/09/12

G. CORRECTED 08/09/12

H. Second Floor, Lab, which is referred to as being 12, 000 square feet in area is deemed as a hazardous area, due to the numerous rooms that are unoccupied and currently being used as storage. The following was observed:

1. The afternoon of 2/-8/2012 The Life Safety floor plan does not indicate that this area is separated from the exit access corridor by self closing positive latching doors.

2. CORRECTED 08/09/12

Based on random observation during the survey walk-through, not all exit enclosures are maintained as fire resistive assemblies in accordance with 19.3.1.1, 7.1.3.2 and 8.2.3. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:
A. The door from the center stair to the elevator Penthouse was not labeled as fire resistance rated.

B. The 10th floor stair pair of doors were not provided with a coordinator to allow the doors to close properly after the non-astragal door is opened.

C. Also see K20. The 6th, 7th and 8th floor renovations have constructed temporary barriers at the center stair to make this stair unavailable for use to allow construction of the new fire rated enclosing wall door assembly. The temporary construction does not maintain the required 2-hour rated stair enclosure.

D. Also see K29. The north stair from the Lower Level discharges to the 1st floor into a designated exit passageway. The exit passageway is not maintained with fire barrier construction from the area under construction.

E. The stair enclosure doors at the south end of the 1st floor Radiology area were observed not to be self-closing to a latched condition.
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Based on random observation during the survey walk-through, not all stairs are constructed and maintained in accordance with 19.2.2.3 and 7.2. These deficiencies could affect all persons required to utilize the exit components by preventing those occupants from safely reaching an exit from the building.

Findings include:
A. The stair from the Penthouse to the Elevator Equipment room is not provided with handrails to comply with 7.2.2.4.

B. The Fire Escape Stair required and permitted as the 2nd means of egress from the 10th and 11th floor existing non-healthcare occupancy floors is obstructed by a window air conditioner at the 10th floor level. Protection of Openings for the Fire Escape Stair in accordance with 7.2.8.2 was not confirmed at all levels.
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Based on random observation during the survey walk-through, not all exit or exit access doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:
A. Doors equipped with magnetic locking devices do not comply with all requirements of 19.2.2.2.4 and 7.2.1.6. Conditions and locations observed:

1. The Emergency Dept. west corridor doors are designated as an exit access and are equipped with magnetic locking devices which are capable of being locked and unlocked remotely but it is not clear that they can be unlocked locally. Staff indicated that they may not be provided with a delayed egress function to comply with 7.2.1.6.1.

2. The 4th floor double egress cross corridor doors defining a south suite area are equipped with magnetic locking devices which failed to allow egress from the suite when tested under fire alarm activation. The doors could not be activated by keycard until the fire alarm was reset. No delayed egress function appeared to be available under non-fire alarm conditions to comply with 7.2.1.6.1.

B. Doors are equipped with hardware which requires more than a single releasing operation to operate the door in non-compliance with 7.2.1.5.4. Conditions and locations include but are not necessarily limited to the following:

1. The 11th floor Sacristy corridor door has both a dead bolt lock and a latchset.

2. The 9th floor Conference room adjacent 9S14C has both a dead bolt lock and a latchset.

3. The 9th floor Laundry room and the adjacent Shower room 9S18 have both a dead bolt lock and a latchset.

4. The Lower Level Tool Room inside the Electrical Store Room is provided with a hasp and padlock that can prevent egress from the room.

5. The Lower Level TV Service Program Office BS11 has both a dead bolt lock and a latchset.

6. The Lower Level Resale Shop rear door has both a dead bolt lock and a latchset.

7. The 1st floor Kitchen Pantry 1N09J has both a dead bolt lock and a latchset.

C. A bread rack cart was observed stationed in the stair enclosure accessed from the Kitchen area in non-compliance with 7.1.3.2.3.
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From random observation the surveyor accompanied by the Director of Facility's finds that the facility has locked doors in identified paths of egress that do not comply with 7.2.1. This condition affects all persons within the facility and could cause a delay of evacuation during a fire particularly for any staff, patients or visitor that are not intimately familiar with the facility

Findings include:

A. Exit access corridors lack at least two exits as required by 19.2.5.9.
Locations observed include:

1. The morning of 02/07/2012, Tenth Floor corridor by Rooms 1022 and 1003. This appears to be a typical case on every floor.

B. Dead end corridors of excessive length appear to exist due to exit sign arrangements and lacking of exit signs to comply with 19.2.5.10. Locations observed include:

1. The morning of 02/07/2012, Tenth Floor Corridor T10034 and Corridor T10030.



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C. Numerous doors are equipped with hardware which requires more than a single releasing operation to operate the door which does not comply with 7.2.1.5.4. Further, many of these doors lack a thumbturn on the egress side of the deadbolt, thus allowing someone to be locked in. Locations as follows:

1. The morning of 02/08/2012First Floor, O.R. corridor doors have both a dead bolt lock and a latchset.

2. CORRECTED 08/09/12
3. CORRECTED 08/09/12

4. The morning of 02/08/2012, 9th Floor: The doors to the G.I Recovery Room are equipped with thumbturn deabolt retractors..

D. Numerous exit access corridors lack at least two exits to comply with 19.2.5.9. Example locations observed:

1. The afternoon of 02/08/2012 Second Floor, corridor adjacent to Lab, appears to be a dead end corridor of a length exceeding 75 feet due to the lack of exit sign placement.

2. The afternoon of 02/08/2012 Second Floor corridor adjacent to the LDR, North end corridor adjacent to Triage and Conference rooms, appears to lack two means of egress due to closing of cross corridor doors which cover the location of directional exit signs. This condition does not comply with 19.2.5.10 and was frequently found through out the facility.

3. CORRECTED 08/09/12
4. The afternoon of 02/08/2012 Third Floor corridor which runs north/south between the Kitchen Servery area and Chapel, Conference rooms passes through a large Conference room at the south end. This does not comply with 19.2.5.9 for the placement of an intervening room or 19.2.5.10 for a dead end corridor of excessive length.

From random observation during the survey walk-through the surveyor accompanied by the Director of Facilities finds that not all designated suites comply with 19.2.5 concerning the maximum allowed square footage. This condition may affect patients, staff and visitors during a fire emergency by increasing the amount of time and travel distance required to reach an exit access corridor.

Findings include:

A. The afternoon of 02/07/2012: Fifth Floor - Designated CCU suite was identified to be 5,941 square feet which is in excess of 5,000 square feet and therefore, does not comply with 19.2.5.6.


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B. The afternoon of 02/08/2012 Second Floor Lab suite is designated as a 12,200 square foot suite which does not comply with 19.2.5.6. The common path of travel appears to exceed the maximum allowed to the nearest exit access corridor.

C. CORRECTED 08/09/12

Based on random observation during the survey walk-through, not all patient sleeping room doors are provided with door hardware arranged so that the patient can open the door from the inside in accordance with 19.2.2.2.2. These deficiencies could affect any patients on the floor of the facility, as well as any staff and visitors present, by preventing those occupants from being able to exit the room(s).

Findings include:
A. The 9th floor Psych unit with a capacity of 18 was observed to have patient sleeping room corridor doors equipped with locking hardware indicated to allow the rooms to be locked to prevent entry into the rooms. However, when staff demonstrated the function of the locks, it was possible to lock the doors to prevent egress from the rooms. Patient sleeping rooms 9S20 and 9S42 were observed, but all sleeping rooms appeared to be equipped with similar hardware. Although two seclusion/restraint rooms existed and are designed for that purpose with monitoring/observation, the individual patient sleeping rooms are not.
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From random observation during the survey walk-through the surveyor while accompanied by the Director of Facility's finds that not all patient sleeping room doors are provided with door hardware arranged so that the patient can open the door from the inside to comply with 19.2.2.2.2. These deficiencies could affect patients and staff by preventing those occupants from being able to exit the room(s).

Findings include:

A. The afternoon of 02/06/2012 and the morning of 02/07/2012, Floors observed are the Eleventh through the Sixteenth Psych patient units. Patient sleeping room corridor doors are equipped with locking hardware indicated to allow the rooms to be locked to prevent entry into the rooms. However, the function of the separate dead bolt locks, (lacking a thumbturn on the room side) makes it possible to lock the doors to prevent egress from the rooms.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies as required by NFPA 101, 8.2.3.2.4.1&2.

Findings include:
A. 2nd floor, at South end 2 hour rated wall, 5 conduits (wire) penetrate the wall and were not sealed.


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B. The Lower Level fire doors north of the Elevator Lobby failed to close properly due to improper function of the coordinator hardware.

C. The 3rd floor fire barrier vestibule, east door of the south pair of cross corridor doors did not close to latch under fire alarm activation.
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From random observation during the survey walk-through, while accompanied by facility representatives the survyeor finds that not all portions of the building's fire/smoke barriers are of fire resistive construction to comply with 19.1.6.2. Designated fire separation walls are not continuous. These deficiencies could affect all patients, as well as staff and visitors due to required fire separation barriers that are not completely protected to prevent the spread of fire from these areas.

Findings include:

A. The morning of 02/08/2012: By direct observation during fire alarm testing the cross corridor fire doors in the Emergency Department and the lower level by Housekeeping could not close to a secure position because the edge of the door was was caught on the rubber wall base.


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B. The morning of 02/07/2012, The designated three (3) hour fire separation wall to the 10th Floor - Telemetry Unit near the STAFF ONLY Toilet Room was observed with conduit penetrations along with a ductwork penetration which has a gap around it that is not sealed against fire to comply with 8.2.3.4.4.2.

C. The morning of 02/07/2012, 8th Floor Telemetry/MedSurge by the Center Nurse Station near Rest Room Staff 846: Designated three (3) hour fire rated wall was observed with a conduit penetration that is not fire sealed to comply with 8.2.3.4.4.2.

D. The afternoon of 02/08/2012, 2nd Floor LDRP Unit- Duct penetrations were observed to lack fire dampers. Location observed near the LDR 2.

E. The afternoon of 02/08/2012, 2nd Floor LDRP Unit- Designated three (3) hour fire separation wall was observed with duct penetrations that are not installed properly to comply with 8.2.3.2.4.1, NFPA 90A 1999 3-3.1.1.

Based on the review of the facilities documents it was determined that the facility failed to maintain a written plan for the protection of residents to provide a prompt and effective response in the event of a fire emergency in accordance with LSC, Section 19.7.2.1.

Findings include:
A. On 2/6/12 at 1:05 PM during the document review of the Fire Safety Plan it was determined that the plan was not direct and explicit with proper procedures as outlined in NFPA 101 Section 19.7.2.1 "Procedures in Case of Fire" and Section 19.7.2.2 outlining what a written fire safety plan should include. The facilities document was vague and parts of the "R. A. C. E." were unclear.

1. Hospital Fire Emergency Plan (code red) # 1487.70, title 191.02 dated 4/16/10, under " Process " , 2. Fire Prevention & Safety, 2.2 " Do not block or obstruct exit passageways; keep all equipment to one side of hallway. " Equipment is never allowed to be located / stored in the exit corridor based on NFPA 101 7.1.10.

2. Mechanical System Smoke Detectors #1787.70, title 309.01 dated June 2007, under 2.2 Personnel Response the plan indicates announcing " code red " , however did not include " RACE " as in the Fire Emergency Plan. When Code Red is announced, it is not clear how staff determines if it is for fire / smoke or which document procedures are to be followed.

Based on record review it was determined that the facility failed to document that fire drills are being conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintainance engineers, and adminsitrative staff) with the signals and emergency action as required. Fire drills are not being held at unexpected times under varying conditions, at least quarterly on each shift.

Findings include:
A. During a record review it was determined that quarterly fire drills do not meet the requirement of varying conditions (times) in all shifts throughout the annual cycle. NFPA 101 Section 19.7.1.2 requires varying times per shift to be documented.

1. 2011 Fire drills were documented as follows:

1st shift is said to be 7:30am to 3:30pm
2nd shift is said to be 3:30pm to 11:00pm
3rd shift is said to be 11:00pm to 7:30am

January 18-6:30am-3rd shift
February 23-1:00pm-1st shift
March 21-4:00pm-2nd shift
April 19-5:00am-3rd shift
May 23-8:00am-1st shift
June 20-4:30pm-2nd shift
July 18-7:00am-3rd shift
August 29-9:00am-1st shift
September 22-3:30pm-2nd shift
October 20-6:00am-3rd shift
November 18-1:00pm-1st shift
December-no documentation reviewed

The above documentation indicates a pattern which consistantly conducts the drills for 3rd shift at the end of the shift and drills for the 2nd shift at the beginning of the shift. Drills are consistantly conducted near the 3rd week of the month.
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Based on random observation during the survey walk-through, not all portions of the building fire alarm system are maintained in accordance with 19.3.4 and NFPA 72.

Findings include:
A. The facility contains old smoke detectors and new detectors in the same area. It could not be determined if the old units are still functioning, are currently being tested or if they were abandoned in place.

1. 5th Floor North Nursing Station storage room contained two hard wired smoke detectors. The unit identified as the older unit is not sealed / or supported at the ceiling, leaving an unsealed penetration in the ceiling plaster.

B. 2nd Floor OR 3, substerile room contained a smoke detector located within 3' of the air supply diffuser and not in accordance with NFPA 72-1999, 2-3.5.1.



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C. The smoke detection was not installed at the high points of the ceiling to comply with NFPA 72-1999, 2-3.4.3.1. The 1st floor Main Lobby detection was provided at the lower ceiling panels of the multi-level ceiling and not at the higher part of the ceiling. The highest part of the ceiling was not provided with smoke detection.
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From random observation during the survey walk-through the surveyor accompanied by the Director of Facilities finds that not all portions of the building fire alarm system are installed to comply with 19.3.4. This condition may prevent emergency egress from the location of fire origin to an adjacent compartment. This condition may affect patients, staff and visitors throughout the facility.

Findings include:

A). The afternoon of 2/8/2012, Third floor Spiritual Services Sleep room (on-call) lacks a visual notification device.
UPDATE 08/09/12 The installation is not complete, boxes and conduit are set in place, devices require installation.

From random observation during the survey walk through the surveyor accompanied by the Director of Facility's finds that failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed activation. This condition may affect patients, staff and visitors within the building. The exceptions used in this building for sprinkler protection do not apply if the sprinkler system is not installed to comply with NFPA 13, 1999. (Example: smoke dampers would be required at duct penetrations through smoke barriers on the ninth floor without full sprinkler protection).

Findings include:

A. CORRECTED 08/09/12


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B. CORRECTED 08/09/12


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C. The morning of 02/08/2012, The facility failed to provide fire suppression for the following areas:

1. Lower level, corridor outside of Financial Systems Product Mgr (as indicated on the Life Safety floor plans).

2. CORRECTED 08/09/12

3. Ninth Floor, this patient care floor lacks sprinkler protection. Due to this K-Tag item, this building is not considered fully sprinkler protected (refer to K-Tag 020).

D. CORRECTED 08/09/12

From random observation during the survey walk-through, the surveyor accompanied by the Maintenance Engineer finds that sprinkler heads are not maintained, inspected and tested periodically in accordance with NFPA 13, and NFPA 25. This condition can lead to a poorly maintained system which can fail during a fire emergency affecting all patients, staff and visitors.

Findings include:

A. The morning of 02/07/2012, Sprinkler heads were observed coated with dust that are not maintained to comply with NFPA 25 1998 2-2.1.1 . Locations observed include:

1. Tenth Floor by the Nurse Station across Room 1012.

2. Seventh Floor by the Nurse Station.

3. Seventh Floor Nurses' Kitchen Room.

4. Third Floor, Womens' Toilet near the Cafeteria.

1. CORRECTED 08/09/12
2. CORRECTED 08/09/12
3. CORRECTED 08/09/12

B. The morning of 02/07/2012, Sprinkler heads missing escutcheon plates do not comply with NFPA 25 1998 2-2.1.1. Locations observed include:

1. Seventh Floor, Med / Surg - Nutrition Room.

2. Seventh Floor, Communication Closet

3. Third Floor, Kitchen Storage inside the Media Services Room 304 by the Administration Area.

4. Third Floor, Food Service - Housekeeping Room.

5. CORRECTED 08/09/12
6. CORRECTED 08/09/12

From random observation during the survey walk through the surveyor accompanied by the Director of Facility's finds that fire dampers are not installed and maintained to comply with NFPA 90A .Failure to test and maintain fire dampers will result in failure of fire dampers during non-emergency conditions which will disrupt air distribution and failure of fire dampers in a fire emergency which could allow migration of fire and smoke to spread throughout patient areas and to multiple patient floors.

A. The morning/afternoon of 02/08/2012, Based on direct observation, the surveyor finds:

1. The facility failed to provide fire protection devices (fire dampers) for the through the floor Class 1 duct (5 inch flex) penetrations supplying ventilation air to the under window room induction units on floors 5 through 16, as required by NFPA 90A, 1999, 3-3.2.

2. The facility failed to identify and maintain the installed 5 inch supply fire dampers penetrating the shaft containing the high pressure ventilation supply risers for the under window room induction units on floors 5 through 16 as required by NFPA 90A, 1999, 3-3.4.1. These dampers do not appear to be listed on the facility ' s damper inventory.

3. The facility failed to provide all openings in ceilings so that service openings in air ducts are accessible for maintenance and inspection needs as required by NFPA 90A, 1999, 2-3.4.5. Not all 5 inch supply fire dampers penetrating the shaft containing the high pressure ventilation supply risers for the under window room induction units on floors 5 through 16 have service access through the plaster ceiling.

4. Not all access and service openings for installed fire dampers, smoke dampers and fire /smoke dampers throughout the facility, are identified in the manner prescribed by NFPA 90A, 1999, 2-3.4.1 & 2-3.4.2. The service access is not identified with letters having a minimum height ½ inch to indicate the fire protection device within.


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B. CORRECTED 08/09/12

A. By direct observation on the morning of 02/06/2012 the surveyor while accompanied by the facility representatives finds, in the 17th floor mechanical room, the duct connections to the utility fan set for the third floor kitchen grease hood exhaust are not by way of flanges and bolted in compliance with NFPA 96, 1998, 5-1.3. The connections are by way of fabric collars and they do not appear to be a listed device. This condition may contribute to a fire event with the mechanical room equipment failure, that could affect patients, staff and visitors.

From random observation during the survey walk-through on the surveyor while accompanied by the Facility Director and Head of Maintenance, finds that not all means of egress are continually maintatined free of all obstructions or impediments to use as required by 7.1.10. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

Findings include:

A. CORRECTED 08/09/12


B. The afternoon of 02/08/2012, 6th Floor Med/ Surg:: Carts and Nurse carts restricts the 8'-0" width corridor.


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C. The afternoon of 02/08/2012, Corridor surrounding the Surgery suite - numerous carts, equipment, containers of combustible materials covered in plastic were observed within the corridors.

D. CORRECTED 08/09/12

E. The morning of 02/08/2012, First Floor level - ICU corridor contains numerous, charting stations with seats, carts, containers lined up on one side of the means of egress corridor restricting the width to less than the required amount.

F. CORRECTED 08/09/12

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

B. An unsecured acetylene tank was observed to be stored with combustibles in the Lower Level Shop in non-compliance with NFPA 51-1997, 2-2.1.
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A. Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

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. Without service from both normal and emergency power, critical care areas could be left without power if a transfer switch fails.

Findings include:
A. Staff was not able to locate were the med gas piping was bonded as required by NFPA-70, Section 250.104(c).

B. Operating rooms, and recovery areas did not have receptacles from both a normal and a critical power source as required by NFPA-99, Section 3-3.2.1.2(a)(1), and NFPA-70, Section 517-19.

C. Some critical panels such as panel 9CL-1 were feeding fire alarm loads that should have been served by the life safety branch panels in accordance with NFPA-70, Section 517-32. These breakers should also be marked in red and have a breaker locking device on them to comply with NFPA-72, Section 1-5.2.5.2.

D. The fifth floor north unit patient rooms are not provided with both normal and emergency receptacles as required by NFPA-70-517-18. It was not determined at the time of the survey whether these beds were classified/certified as med-surg or metal health. All med-surg beds are required to have both normal and emergency receptacles.

E. The operating rooms were not equipped with battery operated emergency lighting as required by NFPA-99, Section 3-3.2.1.2(a)5e.

F. Some electrical boxes in the mechanical rooms and other location were not properly covered in accordance with NFPA-70, Section 370-28(c).

G. The operating rooms, recovery rooms, nursery, and other critical care area receptacles do not have the panel and circuit number designations labeled on all receptacles as required by NFPA 70-1999, 517-19.
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From random observation during the survey walk-through the surveyor while accompanied by the facility electrician, finds that not all portions of the building systems are installed in accordance with NFPA 70 (1999). During a fire event this condition may lead to a lack of power for critical care areas which could affect patients, staff and visitors.

Findings include:

A. The morning of 02/08/2012, The operating rooms were not equipped with battery operated emergency lighting as required by NFPA-99, Section 3-3.2.1.2(a)5e.

B. The morning of 02/08/2012, Normal power receptacles were not provided in operating rooms, and recovery rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these areas could be left with no power.

C. The morning of 02/08/2012 staff was not able to locate were the med gas piping was bonded as required by NFPA-70, Section 250.104(c).

D. The afternoon of 02/08/2012, Some electrical boxes in the mechanical rooms and other location were not properly covered in accordance with NFPA-70, Section 370-28(c).

E. The afternoon of 02/08/2012, The generator room for units #1 and #2 did not have receptacles on emergency power served from the life safety panel in accordance with NFPA-70, Section 517-32.

F. The afternoon of 02/08/2012, In the generator room for unit #3, the lighting and receptacles were not served from a life safety panel in aaccordance with NFPA-70, Section 517-32.

G. The morning of 02/08/2012, The med gas alarm on the 12th floor was fed from a critical panel, (12-CL-2B), instead of a life safety panel as required by NFPA-70, Section 517-32. This was the case on most other floors.

H. The morning of 02/08/2012, The nurse's station on the 11th floor and the med room on most floors did not have lighting and receptacles on an emergency source of power as required by NFPA-70, Section 517-33.

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:
A. The surveyor could not identify a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53.

B. NFPA-99, Section 3-4.2.2.2(b)6 requires elevator cab lighting disconnects to be served from the Life Safety branch of the emergency power system. Panel C-LP12-1, a critical panel, had circuit breakers marked as elevator cab lighting.
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