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Based on observation the surveyor finds a number of fire dampers that are not installed in accordance with NFPA 90A. Failure to provide and maintain fire rated shaft enclosures and fire dampers at shaft penetrations will allow fire to spread from floor to floor in a fire emergency.

Findings include:

A. Corrected 07/15/14

B. Based on observation, the surveyor finds that vertical openings are not protected in accordance with 8.2. of NFPA 101 - 2000 and/or NFPA 90A - 1999. Location observed include:

1. First Floor, A shaft for sprinkler risers were observed with voids and penetrations through walls that are not fire sealed and with ventilation duct penetration that is not fire sealed and is not installed with retaining angles in accordance with a tested design for fire dampers. This shaft is located next to Stair B and the Medication Office Room.

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. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. Corrected 7/15/13


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B. Corrected 7/15/13

C. Corrected 7/15/13

D. Corrected 7/15/13

E. On the afternoon of October 29, 2013 6th Floor, Door to the Laundry Chute room is not labeled to provide a 3/4 hour fire rating.
CLARIFICATION 7/15/14: The corridor door which provides access to the laundry chutes was not provided with a 3/4 hour fire rating as required by NFPA 101, 9.5.1. This was observed on all floors.

F. Corrected 7/15/13

G. Corrected 7/15/13

H. Corrected 7/15/13

I. Corrected 7/15/13

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. Corrected 07/15/14

B. Doors in the means of egress were observed which are identified by illuminated exit signs but which are secured against egress by locking devices as prohibited by 19.2.2.2.4. Locations observed include:

1. 2:20 PM on October 29, 2013: Third Floor Psychiatric Unit.
2. Corrected 07/15/14

C. Corrected 07/15/14

D. Corrected 07/15/14

E. Corrected 07/15/14

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. These deficiencies could affect any patients, staff, or visitors in theareas of the deficiencies cited becasue the activation of or response to the building fire alarm system could be delayed.

Findings include:

A. Corrected 07/15/14

B. Corrected 07/15/14


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C. Corrected 07/15/14

D. Based on observation during fire alarm testing on the morning of October 31, 2013. The surveyor notes that the double doors to the POB with automatic open function did not disable during activation of the system.


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E. The main fire alarm panels, the NAC panels, and the duct detector panels were located in unmanned locations and the rooms where panels were located were not equipped with smoke detectors as required by NFPA-72, Section 1-5.6.

F. The fourth floor north elevator lobby was not equipped with a fire alarm audible or visual fire alarm device and did not meet the requirements of NFPA-72, Section 4-3.2.

Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the fire pump installation did not meet all of the requirements of NFPA-20. This could affect all occupants of the building if the fire pump does not operate during fire emergency.

Findings include:

A. The fire pump was not equipped with the four required alarm points as required by NFPA-20, Section 7-4.7: a) loss of phase, b) pump running, c) phase reversal, and d) connected to emergency source of power.

Based on random observation during the survey walk-through, staff interview, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the immediate area because fire could be permitted to pass between building stories.

Findings include:

A. Corrected 07/15/14

B. Corrected 07/15/14

C. On the morning of October 30, 2013, Third Floor, the designated two hour fire separation wall near the Director of Facilities office was observed with a non self-closing and a non rated door which is required to be 1 1/2 fire rated.
CLARIFICATION 07/15/14: All walls surrounding the stair/ramp vestibule are shown as 2 hour fire rated on the Life Safety Code drawings. The doors to the corridor and mechanical room are located in the 2 hour rated walls on the drawings and therefore must also meet the rating requirement. No labels could be found on these doors.

D. Corrected 07/15/14

Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the generator installation did not meet all of the requirements of NFPA-110. This could affect all occupants of the building if the generator does not operate during the loss of normal power.

Findings include:

A. Corrected 07/15/14

B. The facility's remote annunciator was not located at a location that was staffed 24/7 as required by NFPA-99, Section 3-4.1.1.15.

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.

Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. Panels LP-LL, and Panel ESS2 in the main electrical room had mixed loads that were not separated into the proper emergency branches as required by NFPA-70, Section 517-32 through 517-34.

Based on random observation with the O.R. Manager and the Maintenance Technician present the surveyor finds that electrical installations and materials do not comply with NFPA 70-1999:

Findings include:

A. Corrected 07/15/14


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Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect any patient undergoing surgery if the transfer switch serving the operating rooms fails.

Findings include:

B. The operating rooms were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.