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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. corrected 10/30/13

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. Corrected 10/30/13
1. CORRECTED 08/09/12
2. corrected 10/30/13
3. corrected 10/30/13
D. CORRECTED 08/09/12
E. CORRECTED 04/12/13

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. Corrected 10/31/13



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C. Corrected 10/31/13
1. Corrected 10/30/13
2. CORRECTED 08/09/12
3. CORRECTED 08/09/12
4. Corrected 10/30/13

D. Corrected 10/30/13
1. Corrected 10/31/13
2. Corrected 10/30/13
3. CORRECTED 08/09/12
4. Corrected 10/30/13

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. Corrected 10/30/13
C. CORRECTED 08/09/12

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. Corrected 10/30/13
E. Corrected 10/30/13

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:

1-4. Corrected 10/30/13
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:

1-4. Corrected 10/31/13
5. CORRECTED 08/09/12
6. CORRECTED 08/09/12

NEW: 10/31/13: Ninth Floor, Room 907, Old patient room being used for Storage Room is missing an escutcheon plate.

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. corrected 10/30/13


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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. Corrected 10/30/13
F. CORRECTED 08/09/12

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.

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. Corrected 10/31/13
B. Corrected 10/31/13
C. Corrected 10/31/13
D. Corrected 10/31/13
E. Corrected 10/31/13
F. Corrected 10/31/13

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. Corrected 10/31/13