HospitalInspections.org

Based on observation and testing, the facility failed to provide
the correct building construction type.

Findings include:

While inspecting building construction on 05/25/10 through 5/26/10 the surveyor observed the following deficiencies:
1 )2nd floor south nursery area had unprotected steal above the 2 hour separation wall.
2) 2nd floor south nursery area exit stairway had unprotected steal in the stairway
3) 2nd floor north, west wing in room 2005 had penetrations in the floor ceiling assembly.

These deficient practices have the potential of effecting the entire facility.

Based on observation and testing, the facility failed to provide
walls constructed with at least 1/2 hour fire resistance rating.

Findings include:

While inspecting corridor walls on 05/25/10 through 5/26/10 the surveyor observed penetrations in the following corridor walls:
1) In the C-Section Exit Hallway penetrations throughout.
2) 2nd Floor North, West Wing - hallway across from nursing station was not built to deck and penetrations throughout.
3) 3rd Floor North, Electrical Closet C had a PVC pipe penetrating the corridor wall and sealed with an un-rated sealant.

These deficient practices have the potential of effecting the entire facility.

Based on observation and testing, the facility failed to provide
partitions that have a fire resistance rating of at least one hour.

Findings include:

While inspecting vertical openings on 05/25/10 through 5/26/10 the surveyor observed deficient items in the following vertical shafts:
1) Cart lift extending 5 stories had penetrations throughout.
2) Elevators 1,2,3,4, and 5 penetrations around control panels on backwall of shaft on all 5 floors.
3) Elevator 6 had penetrations around control panel and in shaft walls from the 2nd floor to 1st floor.
4) 3rd Floor South Nursery vertical shaft had penetrations open to the corridor and a non-rated
door. Shaft extended 5 stories.
5) Access panel on 2nd Floor North West Wing was a non-fire rated panel.
6) 5 North 3rd Floor open to corridor a non-rated access panel installed.

These deficient practices have the potential of effecting the entire facility.

Based on observation and testing, the facility failed to provide
doors that automatically close by zone or throughout the facility upon activation.

Findings include:

While inspecting smoke barrier doors on 05/25/10 through 5/26/10 the surveyor observed deficient items in the following smoke barrier doors
1) Smoke Barrier doors going into 3rd Floor Tower did not release when fire alarm was activated.
2) Smoke barrier doors going into 2nd Floor Tower did not release when fire alarm was activated.

These deficient practices have the potential of effecting the entire facility.

Based on observation and testing, the facility failed to provide
partitions of at least a 1/2 hour fire resistance rating and constructed in accordance with 8.3

Findings include:

While inspecting smoke barrier walls on 05/25/10 through 5/26/10 the surveyor observed deficient items in the following smoke barrier walls:
1) Labor and Delivery smoke barrier wall is not constructed to the deck.
2) 2nd Floor South, nursery smoke barrier wall is not constructed to deck.
3) 2nd Floor North, West Wing smoke barrier wall at Room 2005 & Room 2214 had penetrations.
4) 5 North smoke barrier wall had penetrations throughout.
5) 5 Tower, Floors 5,4,3,2 smoke barrier walls are not constructed built to deck. Walls terminate at
bottom of structural beams.

These deficient practices have the potential of effecting the entire facility.

Based on observation and testing, the facility failed to provide 1 hour fire rated construction for hazardous areas.

Findings include:

While inspecting hazardous areas on 05/25/10 through 5/26/10 the surveyor observed deficient items in the following vertical shafts:
1) 5 North, 5th Floor Bio Hazard Room walls should be built to deck inside community ED
coordinator office.
2) 5 North, 3rd Floor Christmas Storage Room did not have a 45 minute rated door or door closer.
3) ICU Soiled Lined Room inside wall not built to deck.
4) Medical Records storage room did not have door closer on two doors.
5) Flammable Storage Room in Lab Area had penetrations in walls, walls not built to deck and did
not have 45 minute door.
6) Lab General Storage did not have a door closer.
7) Oxygen Storage in basement did not have doorcloser.
8) Basement equipment room next to vending had vent in rated door and penetrations throughout.
9) Emergency Room Soiled Linen Room not built to deck.
10) Soiled Laundry Room had penetrations throughout.
11) 2nd Floor South, Nursery Soiled Linen Room was not built to deck.
12) Soiled Linen Room L35 wall not built to deck.
13) 2nd Floor South, Nursery Mechanical Room not built to deck.

These deficient practices have the potential of effecting the entire facility.

Based on observation and testing, the facility failed to provide
all the approved components, devices or equipment installed in according to NFPA 72.

Findings include:

While inspecting fire alarm system on 05/25/10 through 5/26/10 the surveyor observed deficient items in the following fire alarm components:
1) 5th Floor Tower had no strobe located at nursing station.
2) 4th Floor Tower had no strobe located at nursing station.
3) 1st Floor Tower had 3 strobes not operational around nursing station.
4) 5th Floor North needs 3 strobes installed
5) 4th Floor North needs 2 strobes installed
6) 3rd Floor North needs 4 strobes installed
7) 2nd Floor North needs 5 strobes installed
8) 1st Floor North needs 3 strobes installed
9) Nuclear Medicine needs 2 strobes installed
10) Radiology strobes not operational
11) Basement needs strobes installed around Respiratory Therapy, Central Supply, and in hallways.
A total of 9 strobes needs to be installed.

These deficient practices have the potential of effecting the entire facility.

Based on observation and testing, the facility failed to provide
the correct building construction type.

Findings include:

While inspecting building construction on 05/25/10 through 5/26/10 the surveyor observed the following deficiencies:
1 )2nd floor south nursery area had unprotected steal above the 2 hour separation wall.
2) 2nd floor south nursery area exit stairway had unprotected steal in the stairway
3) 2nd floor north, west wing in room 2005 had penetrations in the floor ceiling assembly.

These deficient practices have the potential of effecting the entire facility.

Based on observation and testing, the facility failed to provide
walls constructed with at least 1/2 hour fire resistance rating.

Findings include:

While inspecting corridor walls on 05/25/10 through 5/26/10 the surveyor observed penetrations in the following corridor walls:
1) In the C-Section Exit Hallway penetrations throughout.
2) 2nd Floor North, West Wing - hallway across from nursing station was not built to deck and penetrations throughout.
3) 3rd Floor North, Electrical Closet C had a PVC pipe penetrating the corridor wall and sealed with an un-rated sealant.

These deficient practices have the potential of effecting the entire facility.

Based on observation and testing, the facility failed to provide
partitions that have a fire resistance rating of at least one hour.

Findings include:

While inspecting vertical openings on 05/25/10 through 5/26/10 the surveyor observed deficient items in the following vertical shafts:
1) Cart lift extending 5 stories had penetrations throughout.
2) Elevators 1,2,3,4, and 5 penetrations around control panels on backwall of shaft on all 5 floors.
3) Elevator 6 had penetrations around control panel and in shaft walls from the 2nd floor to 1st floor.
4) 3rd Floor South Nursery vertical shaft had penetrations open to the corridor and a non-rated
door. Shaft extended 5 stories.
5) Access panel on 2nd Floor North West Wing was a non-fire rated panel.
6) 5 North 3rd Floor open to corridor a non-rated access panel installed.

These deficient practices have the potential of effecting the entire facility.

Based on observation and testing, the facility failed to provide
doors that automatically close by zone or throughout the facility upon activation.

Findings include:

While inspecting smoke barrier doors on 05/25/10 through 5/26/10 the surveyor observed deficient items in the following smoke barrier doors
1) Smoke Barrier doors going into 3rd Floor Tower did not release when fire alarm was activated.
2) Smoke barrier doors going into 2nd Floor Tower did not release when fire alarm was activated.

These deficient practices have the potential of effecting the entire facility.

Based on observation and testing, the facility failed to provide
partitions of at least a 1/2 hour fire resistance rating and constructed in accordance with 8.3

Findings include:

While inspecting smoke barrier walls on 05/25/10 through 5/26/10 the surveyor observed deficient items in the following smoke barrier walls:
1) Labor and Delivery smoke barrier wall is not constructed to the deck.
2) 2nd Floor South, nursery smoke barrier wall is not constructed to deck.
3) 2nd Floor North, West Wing smoke barrier wall at Room 2005 & Room 2214 had penetrations.
4) 5 North smoke barrier wall had penetrations throughout.
5) 5 Tower, Floors 5,4,3,2 smoke barrier walls are not constructed built to deck. Walls terminate at
bottom of structural beams.

These deficient practices have the potential of effecting the entire facility.

Based on observation and testing, the facility failed to provide 1 hour fire rated construction for hazardous areas.

Findings include:

While inspecting hazardous areas on 05/25/10 through 5/26/10 the surveyor observed deficient items in the following vertical shafts:
1) 5 North, 5th Floor Bio Hazard Room walls should be built to deck inside community ED
coordinator office.
2) 5 North, 3rd Floor Christmas Storage Room did not have a 45 minute rated door or door closer.
3) ICU Soiled Lined Room inside wall not built to deck.
4) Medical Records storage room did not have door closer on two doors.
5) Flammable Storage Room in Lab Area had penetrations in walls, walls not built to deck and did
not have 45 minute door.
6) Lab General Storage did not have a door closer.
7) Oxygen Storage in basement did not have doorcloser.
8) Basement equipment room next to vending had vent in rated door and penetrations throughout.
9) Emergency Room Soiled Linen Room not built to deck.
10) Soiled Laundry Room had penetrations throughout.
11) 2nd Floor South, Nursery Soiled Linen Room was not built to deck.
12) Soiled Linen Room L35 wall not built to deck.
13) 2nd Floor South, Nursery Mechanical Room not built to deck.

These deficient practices have the potential of effecting the entire facility.

Based on observation and testing, the facility failed to provide
all the approved components, devices or equipment installed in according to NFPA 72.

Findings include:

While inspecting fire alarm system on 05/25/10 through 5/26/10 the surveyor observed deficient items in the following fire alarm components:
1) 5th Floor Tower had no strobe located at nursing station.
2) 4th Floor Tower had no strobe located at nursing station.
3) 1st Floor Tower had 3 strobes not operational around nursing station.
4) 5th Floor North needs 3 strobes installed
5) 4th Floor North needs 2 strobes installed
6) 3rd Floor North needs 4 strobes installed
7) 2nd Floor North needs 5 strobes installed
8) 1st Floor North needs 3 strobes installed
9) Nuclear Medicine needs 2 strobes installed
10) Radiology strobes not operational
11) Basement needs strobes installed around Respiratory Therapy, Central Supply, and in hallways.
A total of 9 strobes needs to be installed.

These deficient practices have the potential of effecting the entire facility.