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Based on surveyor observation it was determined that the facility failed to maintain corridor doors in conformance with NFPA 101 Section 19.3.6.3. for five patient rooms located on the third floor unit.

Findings are as follows::

Observations on 12/2/10 of the third floor unit revealed that the corridor doors of five patient rooms (not currently occupied by patients), were obstructed from closing, as required, by surplus hospital beds being stored in the rooms.

Based on surveyor observation and staff interview, it was determined that the facility failed to maintain the exit passageway doors in conformance with NFPA 101 Section 19.2.2.2.6.

Findings are as follows:

NFPA 101 Section 19.2.2.2.6 requires that any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with section 7.2.1.8.2.

Observation on 12/1/10 of the ground floor laundry chute room, revealed that the self-closing door to the room was being held open by a rope wrapped around the doorknob and tied to the interior wall. Additionally, on 12/2/10 the same door was observed to be propped open by a metal piece of electrical conduit.

When questioned by the surveyor the hospital's Construction Manager acknowledged that the door should remain closed when not in use.

Based on surveyor observation, it was determined that the facility failed to maintain the exit passageway doors in conformance with NFPA 101 Section 19.2.2.2.6.

Findings are as follows:

NFPA 101 Section 19.2.2.2.6 requires that any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with section 7.2.1.8.2.

Observation of the 3rd floor Mechanical Room revealed that the fire exit door to the southwest stairway was prohibited from closing by a towel wedged at the bottom of the door.

Based on surveyor observation, the facility failed to maintain the smoke barriers in accordance with NFPA 101 Section 8.3.

Findings are as follows:

Inspection of the smoke barrier wall (listed as a 2-hour fire wall) located on the ground floor on 12/2/10, revealed that there was an approximate 6 inch x 12 inch penetration of the wall located above the exit door (entering the ramp to the Nursing Arts Building).

Additionally, inspection of the smoke barrier wall (listed as a 2-hour fire wall) located on the third floor on 12/2/10, revealed that there was a 2 inch diameter penetration of the wall located at the double doors (entering the north unit), above the ceiling tiles.

Based on surveyor observations, the facility failed to maintain the smoke barriers in accordance with NFPA 101 Section 8.3.

Findings are as follows:

1. Observation on 12/2/10 of the electrical closet located on the 1st floor (adjacent to the trash and linen collection room), revealed that a 4 inch diameter electrical conduit pipe penetrating the ceiling was not sealed to prevent the passage of smoke.

2. Observation of the smoke barrier wall located on the fourth floor on 12/3/10, revealed that there was an approximate 4 inch diameter penetration of the wall located above the double smoke compartment doors (above the ceiling tiles).

Based on staff interview, it was determined that the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.
Findings are as follows:
Staff interview on 12/3/10 revealed that the Bridge Building, first floor, ED level incorporates the use of two sets of fire rated doors with intumescent seals. The open vertical gap between the opposing doors at each installation was reported to exceed the 1/8" maximum allowance per NFPA 101, Section 8.3.4.1 guidelines, which could facilitate the passage of smoke. The intumescent door seals start to expand at 356 degrees F.

Based on surveyor observation it was determined that the facility failed to ensure that smoke barrier doors are constructed to restrict the movement of smoke.

Findings are as follows:

NFPA 101 Section 8.3.4.1 requires that doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and to be without undercuts, louvers, or grilles. The maximum clearance for proper operation of smoke doors is defined as 1/8 in.

Inspection of the 2-hour rated door (entering the ramp to the Nursing Arts Building) on 12/1/10, located on the ground floor, revealed that the door did not fully close due to the door frame being damaged.

Based on surveyor observation it was determined that the facility failed to provide protection throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 101 Section 13.5-5.6.

Findings are as follows:

NFPA 101 Section 13.5-5.6. requires clearance between the sprinkler deflector and the top of storage to be a minimum of 18 inches.

During the life safety code tour on 12/1/10 at 9:00AM, accompanied by the Maintenance Director, it was revealed that a storage area across from the OR Materials Management Supervisor's office, was stacked with multiple items within 18 inches of the sprinkler deflector.

Based on surveyor observation, it was determined that the facility failed to provide protection throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 13 Section 5-5.6.

Findings are as follows:

1. NFPA 13 Section 5-5.6. requires clearance between the sprinkler deflector and the top of storage to be a minimum of 18 inches.

During the life safety code tour on 12/2/10 at 9:00AM, accompanied by the Maintenance Director, it was revealed that a pharmacy storage area on the basement level contained multiple items that were stored within 18 inches from the sprinkler deflector.

2. NFPA 101 Section 19.3.5.3 requires the provision of complete sprinkler coverage for all portions of the building.

Observation on 12/1/10 at 10:30AM revealed that 14 of 14 walk-in Refrigerator/Freezer units were without sprinkler protection. These areas are considered hazardous and require sprinkler protection.

Based on surveyor observation, it was determined that the facility failed to provide protection throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 13 Section 5-5.6.

Findings are as follows:

NFPA 13 Section 5-5.6. requires clearance between the sprinkler deflector and the top of storage to be a minimum of 18 inches.

During the life safety code tour on 12/6/10 at approximately 9:30AM, accompanied by the Manager of Utilitiy Operations and Maintenance, it was revealed that two closets located in Medical Records Department contained cardboard boxes and paper files that were stored within 18 inches of the sprinkler deflector.

Based on surveyor observation, it was determined that the facility failed to continuously maintain the automatic sprinkler system in reliable operating condition concerning the laundry chute in the George building.

Findings are as follows:

Observation of the interior of the laundry chute at the inlet opening on the third floor of the George building during the Life Safety tour on 6/9/10 at 9:00AM, accompanied by the Manager of Utility Operations and Maintenance, it was noted that the sprinkler head was heavily caked with dust, including the area between the stylines of the sprinkler head.

Based on surveyor observation, it was determined that the facility failed to continuously maintain the automatic sprinkler system in reliable operating condition concerning the laundry chute located in the Meehan building on the 3rd floor.

Findings are as follows:

During the Life Safety tour on 6/9/10 at 10:15AM, accompanied by the Manager of Utility Operations and Maintenance, it was noted that the sprinkler head, was heavily caked with dust, including the area between the stylines of the sprinkler head.

Based on surveyor observations, it was determined that the facility failed to continuously maintain the automatic sprinkler system in reliable operating condition concerning the laundry and trash chutes in the Ambulatory Patient Care (APC) building.

Findings are as follows:

Observation of the inlet openings of both the laundry chute on the eleventh floor, and the trash chute on the twelfth floor of the APC building, during the Life Safety tour on 6/9/10 at 9:00AM, accompanied by the Manager of Utility Operations and Maintenance, it was noted that these sprinkler heads were heavily caked with dust, including the area between the stylines of the sprinkler heads.

Based on surveyor observation, it was determined that the facility failed to provide portable fire extinguishers in all health care occupancies in accordance with NFPA 10 Section 1-6.3.


Findings are as follows:

NFPA 10 Section 1-6.3 requires that fire extinguishers are conspicuously located where they will be readily accessible and immediately available in the event of a fire.

During the life safety code tour on 12/3/10 at 10:30AM, accompanied by the Maintenance Director, it was revealed that a fire extinguisher encased in the rear wall of the cafeteria was observed fully obstructed by ten 2 feet x 3 feet boxes, eight utility carts, two 3 feet x 5 feet boxes and a 9 foot ladder.

Based on surveyor observation, it was determined that the facility failed to provide portable fire extinguishers in all health care occupancies in accordance with NFPA 10 Section 1-6.3.

Findings are as follows:

NFPA 10 Section 1-6.3 requires that fire extinguishers are conspicuously located where they will be readily accessible and immediately available in the event of a fire.

During the life safety code tour on 12/1/10 at 9:00AM, accompanied by the Maintenance Director, a fire extinguisher was observed encased in a wall, partially obstructed by an opened smoke passage door.

Based on surveyor observation and staff interview, it was determined that the facility failed to provide for adequate sprinkler head protection for the laundry chute on the third floor of the George building.

Findings are as follows:

NFPA 82 Section 3-2-5.2 states: Automatic sprinklers installed in gravity chute service openings shall be recessed out of the chute area through which the material travels.

Observation of the interior of the laundry chute at the inlet opening on the third floor of the George building during the Life Safety tour on 6/9/10 at 9:00AM, accompanied by the Manager of Utility Operations and Maintenance, it was noted that the sprinkler head was approximately 4.5 inches above the top of the inlet opening.

When questioned during an interview that immediately followed, the Manager of Utility Operations and Maintenance agreed the sprinkler head was not recessed high enough to avoid contact with laundry material.

Based on surveyor observation, it was determined that the facility failed to provide for adequate chute sprinkler head protection for the trash chute located on the third floor of the Meehan building.

Findings are as follows:

NFPA 82 Section 3-2-5.2 states: Automatic sprinklers installed in gravity chute service openings shall be recessed out of the chute area through which the material travels.

During the Life Safety tour on 6/9/10 at 10:15AM, accompanied by the Manager of Utility Operations and Maintenance, it was noted that the sprinkler head was 2 inches above the top of the inlet opening.

Based on surveyor observation, it was determined that the facility has failed to provide for adequate chute sprinkler head protection for the laundry and trash chutes on multiple floors of the Ambulatory Patient Care (APC) building.

Findings are as follows:

NFPA 82 Section 3-2-5.2 states: Automatic sprinklers installed in gravity chute service openings shall be recessed out of the chute area through which the material travels.

Observation of the interior of the laundry and trash chutes at the inlet openings on the first through twelfth floors of the APC building during the Life Safety Code tour on 12/7/10, accompanied by the Manager of Utility Operations and Maintenance, it was noted that the sprinkler heads were not recessed properly to avoid contact with laundry or trash materials. There was a 2 inch x 2 inch and a 1 inch x 1 inch piece of plastic trash bag attached to the sprinkler heads in the trash chute on the fifth and eleventh floors respectively. Additionally, the sprinkler heads in the laundry chute on the first, second, third, sixth, eigth, ninth and tenth floor had one or more bent stylines.

Based on surveyor observation, it was determined that the facility failed to continuously maintain a means of egress free of all obstructions or impediments to full instant use in the case of a fire or other emergency in accordance with NFPA 101 Section 7.1.10.1.

Findings are as follows:

NFPA 101 Section 7.1.10.1 states, " means of egress shall be continuously maintained free of all obstructions and impediments to full instant use in the case of fire or other emergency."

During the life safety code tour on 11/30/10 at 9:00AM, accompanied by the Maintenance Director, it was revealed that the rear fire exit to the outdoor garden area was partially obstructed with 3 large upholstered sleeping chairs, 3 large metal supply carts, 1 treatment cart and multiple boxes.

In addition, the exit stairway located approximately 20 feet from the fire exit door was partially obstructed by 2 large metal rolling shelves directly in front of the stairway door.

Based on surveyor observation, it was determined that the facility failed to continuously maintain means of egress free of all obstructions or impediments to full instant use in the case of a fire or other emergency in accordance with NFPA 101 Section 7.1.10.1.

Findings are as follows:

NFPA 101 Section 7.1.10.1 states, " means of egress shall be continuously maintained free of all obstructions and impediments to full instant use in the case of fire or other emergency."

During the life safety code tour on 12/2/10, accompanied by the hospital's Construction Manager, it was revealed that the exit corridor located in the south unit was partially obstructed with multiple items being stored in the corridor. Items included two computers on wheels, a trash container, and three stationary medical supply carts.

Based on surveyor observations and staff interview during the Life Safety Code tour, it was determined that the facility has failed to comply with NFPA 99 standards regarding storage requirements for cylinders containing gas on 1 of 3 patient units.

Findings are as follows:

NFPA 99 SECTION 8.3.1.11.2(h) states, "cylinder or container restraint shall meet 4.3.5.2.1 (b) 27", which states, "freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart".

Surveyor observation of the Bridge building's second floor soiled utility room located on the PACU on 11/30/10 at 9:28AM, found one nitrous oxide F size tank (40 cubic feet) which was free standing and was not secured by either a chain or a stand.

When questioned during an interview that immediately followed, the Manager of Utility Operations and Maintenance indicated this tank should have been securely stored at the third floor storage area.

Based on surveyor observation, it was determined that the facility failed to provide protection of medical gas storage in accordance with NFPA 99 Section 8.3.1.11.2(h).

Findings are as follows:

NFPA 99 Section 8.3.1.11.2(h) states, " cylinder or container restraints shall meet 4.3.5.2.1.27 " , which states, " free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart " .

During the life safety code tour on 12/2/10 at 10:30AM, accompanied by the Maintenance Director, it was revealed that two oxygen cylinders and four acetylene cylinders were unsecured in the central area of the floor located on the sub-basement level of the facility.

This Standard is not met as evidence by:

Based on observation, the facility failed to maintain clearance with heating equipment from combustible materials according to the manufacturer's specification.

Findings are as follows:

LSC Section 39.5.1. states:

"Heating, ventilating, and air conditioning equipment shall comply with the provisions of Section 9.2 and in accordance with the manufacturer's specification."

During a Life Safety Code tour of 111 Plain Street on 11/30/10, observation of the lower level mechanical room revealed that several cardboard boxes containing rolls of toilet paper were stored against (zero clearance) a gas heating unit.

This Standard is also not met as evidenced by:

Section 7.1.3.2.3 states:

"An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit."

Based on a Life Safety Code tour at 70 Catamore Boulevard on 12/1/10, two liquid oxygen dewars (containers) were observed located within the exit access corridor. Interview with the facility staff revealed that the liquid oxygen containers were routinely stored in the corridor.

Based on surveyor observation it was determined that the facility failed to maintain corridor doors in conformance with NFPA 101 Section 19.3.6.3. for five patient rooms located on the third floor unit.

Findings are as follows::

Observations on 12/2/10 of the third floor unit revealed that the corridor doors of five patient rooms (not currently occupied by patients), were obstructed from closing, as required, by surplus hospital beds being stored in the rooms.

Based on surveyor observation and staff interview, it was determined that the facility failed to maintain the exit passageway doors in conformance with NFPA 101 Section 19.2.2.2.6.

Findings are as follows:

NFPA 101 Section 19.2.2.2.6 requires that any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with section 7.2.1.8.2.

Observation on 12/1/10 of the ground floor laundry chute room, revealed that the self-closing door to the room was being held open by a rope wrapped around the doorknob and tied to the interior wall. Additionally, on 12/2/10 the same door was observed to be propped open by a metal piece of electrical conduit.

When questioned by the surveyor the hospital's Construction Manager acknowledged that the door should remain closed when not in use.

Based on surveyor observation, it was determined that the facility failed to maintain the exit passageway doors in conformance with NFPA 101 Section 19.2.2.2.6.

Findings are as follows:

NFPA 101 Section 19.2.2.2.6 requires that any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with section 7.2.1.8.2.

Observation of the 3rd floor Mechanical Room revealed that the fire exit door to the southwest stairway was prohibited from closing by a towel wedged at the bottom of the door.

Based on surveyor observation, the facility failed to maintain the smoke barriers in accordance with NFPA 101 Section 8.3.

Findings are as follows:

Inspection of the smoke barrier wall (listed as a 2-hour fire wall) located on the ground floor on 12/2/10, revealed that there was an approximate 6 inch x 12 inch penetration of the wall located above the exit door (entering the ramp to the Nursing Arts Building).

Additionally, inspection of the smoke barrier wall (listed as a 2-hour fire wall) located on the third floor on 12/2/10, revealed that there was a 2 inch diameter penetration of the wall located at the double doors (entering the north unit), above the ceiling tiles.

Based on surveyor observations, the facility failed to maintain the smoke barriers in accordance with NFPA 101 Section 8.3.

Findings are as follows:

1. Observation on 12/2/10 of the electrical closet located on the 1st floor (adjacent to the trash and linen collection room), revealed that a 4 inch diameter electrical conduit pipe penetrating the ceiling was not sealed to prevent the passage of smoke.

2. Observation of the smoke barrier wall located on the fourth floor on 12/3/10, revealed that there was an approximate 4 inch diameter penetration of the wall located above the double smoke compartment doors (above the ceiling tiles).

Based on staff interview, it was determined that the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.
Findings are as follows:
Staff interview on 12/3/10 revealed that the Bridge Building, first floor, ED level incorporates the use of two sets of fire rated doors with intumescent seals. The open vertical gap between the opposing doors at each installation was reported to exceed the 1/8" maximum allowance per NFPA 101, Section 8.3.4.1 guidelines, which could facilitate the passage of smoke. The intumescent door seals start to expand at 356 degrees F.

Based on surveyor observation it was determined that the facility failed to ensure that smoke barrier doors are constructed to restrict the movement of smoke.

Findings are as follows:

NFPA 101 Section 8.3.4.1 requires that doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and to be without undercuts, louvers, or grilles. The maximum clearance for proper operation of smoke doors is defined as 1/8 in.

Inspection of the 2-hour rated door (entering the ramp to the Nursing Arts Building) on 12/1/10, located on the ground floor, revealed that the door did not fully close due to the door frame being damaged.

Based on surveyor observation it was determined that the facility failed to provide protection throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 101 Section 13.5-5.6.

Findings are as follows:

NFPA 101 Section 13.5-5.6. requires clearance between the sprinkler deflector and the top of storage to be a minimum of 18 inches.

During the life safety code tour on 12/1/10 at 9:00AM, accompanied by the Maintenance Director, it was revealed that a storage area across from the OR Materials Management Supervisor's office, was stacked with multiple items within 18 inches of the sprinkler deflector.

Based on surveyor observation, it was determined that the facility failed to provide protection throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 13 Section 5-5.6.

Findings are as follows:

1. NFPA 13 Section 5-5.6. requires clearance between the sprinkler deflector and the top of storage to be a minimum of 18 inches.

During the life safety code tour on 12/2/10 at 9:00AM, accompanied by the Maintenance Director, it was revealed that a pharmacy storage area on the basement level contained multiple items that were stored within 18 inches from the sprinkler deflector.

2. NFPA 101 Section 19.3.5.3 requires the provision of complete sprinkler coverage for all portions of the building.

Observation on 12/1/10 at 10:30AM revealed that 14 of 14 walk-in Refrigerator/Freezer units were without sprinkler protection. These areas are considered hazardous and require sprinkler protection.

Based on surveyor observation, it was determined that the facility failed to provide protection throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 13 Section 5-5.6.

Findings are as follows:

NFPA 13 Section 5-5.6. requires clearance between the sprinkler deflector and the top of storage to be a minimum of 18 inches.

During the life safety code tour on 12/6/10 at approximately 9:30AM, accompanied by the Manager of Utilitiy Operations and Maintenance, it was revealed that two closets located in Medical Records Department contained cardboard boxes and paper files that were stored within 18 inches of the sprinkler deflector.

Based on surveyor observation, it was determined that the facility failed to continuously maintain the automatic sprinkler system in reliable operating condition concerning the laundry chute in the George building.

Findings are as follows:

Observation of the interior of the laundry chute at the inlet opening on the third floor of the George building during the Life Safety tour on 6/9/10 at 9:00AM, accompanied by the Manager of Utility Operations and Maintenance, it was noted that the sprinkler head was heavily caked with dust, including the area between the stylines of the sprinkler head.

Based on surveyor observation, it was determined that the facility failed to continuously maintain the automatic sprinkler system in reliable operating condition concerning the laundry chute located in the Meehan building on the 3rd floor.

Findings are as follows:

During the Life Safety tour on 6/9/10 at 10:15AM, accompanied by the Manager of Utility Operations and Maintenance, it was noted that the sprinkler head, was heavily caked with dust, including the area between the stylines of the sprinkler head.

Based on surveyor observations, it was determined that the facility failed to continuously maintain the automatic sprinkler system in reliable operating condition concerning the laundry and trash chutes in the Ambulatory Patient Care (APC) building.

Findings are as follows:

Observation of the inlet openings of both the laundry chute on the eleventh floor, and the trash chute on the twelfth floor of the APC building, during the Life Safety tour on 6/9/10 at 9:00AM, accompanied by the Manager of Utility Operations and Maintenance, it was noted that these sprinkler heads were heavily caked with dust, including the area between the stylines of the sprinkler heads.

Based on surveyor observation, it was determined that the facility failed to provide portable fire extinguishers in all health care occupancies in accordance with NFPA 10 Section 1-6.3.


Findings are as follows:

NFPA 10 Section 1-6.3 requires that fire extinguishers are conspicuously located where they will be readily accessible and immediately available in the event of a fire.

During the life safety code tour on 12/3/10 at 10:30AM, accompanied by the Maintenance Director, it was revealed that a fire extinguisher encased in the rear wall of the cafeteria was observed fully obstructed by ten 2 feet x 3 feet boxes, eight utility carts, two 3 feet x 5 feet boxes and a 9 foot ladder.

Based on surveyor observation, it was determined that the facility failed to provide portable fire extinguishers in all health care occupancies in accordance with NFPA 10 Section 1-6.3.

Findings are as follows:

NFPA 10 Section 1-6.3 requires that fire extinguishers are conspicuously located where they will be readily accessible and immediately available in the event of a fire.

During the life safety code tour on 12/1/10 at 9:00AM, accompanied by the Maintenance Director, a fire extinguisher was observed encased in a wall, partially obstructed by an opened smoke passage door.

Based on surveyor observation and staff interview, it was determined that the facility failed to provide for adequate sprinkler head protection for the laundry chute on the third floor of the George building.

Findings are as follows:

NFPA 82 Section 3-2-5.2 states: Automatic sprinklers installed in gravity chute service openings shall be recessed out of the chute area through which the material travels.

Observation of the interior of the laundry chute at the inlet opening on the third floor of the George building during the Life Safety tour on 6/9/10 at 9:00AM, accompanied by the Manager of Utility Operations and Maintenance, it was noted that the sprinkler head was approximately 4.5 inches above the top of the inlet opening.

When questioned during an interview that immediately followed, the Manager of Utility Operations and Maintenance agreed the sprinkler head was not recessed high enough to avoid contact with laundry material.

Based on surveyor observation, it was determined that the facility failed to provide for adequate chute sprinkler head protection for the trash chute located on the third floor of the Meehan building.

Findings are as follows:

NFPA 82 Section 3-2-5.2 states: Automatic sprinklers installed in gravity chute service openings shall be recessed out of the chute area through which the material travels.

During the Life Safety tour on 6/9/10 at 10:15AM, accompanied by the Manager of Utility Operations and Maintenance, it was noted that the sprinkler head was 2 inches above the top of the inlet opening.

Based on surveyor observation, it was determined that the facility has failed to provide for adequate chute sprinkler head protection for the laundry and trash chutes on multiple floors of the Ambulatory Patient Care (APC) building.

Findings are as follows:

NFPA 82 Section 3-2-5.2 states: Automatic sprinklers installed in gravity chute service openings shall be recessed out of the chute area through which the material travels.

Observation of the interior of the laundry and trash chutes at the inlet openings on the first through twelfth floors of the APC building during the Life Safety Code tour on 12/7/10, accompanied by the Manager of Utility Operations and Maintenance, it was noted that the sprinkler heads were not recessed properly to avoid contact with laundry or trash materials. There was a 2 inch x 2 inch and a 1 inch x 1 inch piece of plastic trash bag attached to the sprinkler heads in the trash chute on the fifth and eleventh floors respectively. Additionally, the sprinkler heads in the laundry chute on the first, second, third, sixth, eigth, ninth and tenth floor had one or more bent stylines.

Based on surveyor observation, it was determined that the facility failed to continuously maintain a means of egress free of all obstructions or impediments to full instant use in the case of a fire or other emergency in accordance with NFPA 101 Section 7.1.10.1.

Findings are as follows:

NFPA 101 Section 7.1.10.1 states, " means of egress shall be continuously maintained free of all obstructions and impediments to full instant use in the case of fire or other emergency."

During the life safety code tour on 11/30/10 at 9:00AM, accompanied by the Maintenance Director, it was revealed that the rear fire exit to the outdoor garden area was partially obstructed with 3 large upholstered sleeping chairs, 3 large metal supply carts, 1 treatment cart and multiple boxes.

In addition, the exit stairway located approximately 20 feet from the fire exit door was partially obstructed by 2 large metal rolling shelves directly in front of the stairway door.

Based on surveyor observation, it was determined that the facility failed to continuously maintain means of egress free of all obstructions or impediments to full instant use in the case of a fire or other emergency in accordance with NFPA 101 Section 7.1.10.1.

Findings are as follows:

NFPA 101 Section 7.1.10.1 states, " means of egress shall be continuously maintained free of all obstructions and impediments to full instant use in the case of fire or other emergency."

During the life safety code tour on 12/2/10, accompanied by the hospital's Construction Manager, it was revealed that the exit corridor located in the south unit was partially obstructed with multiple items being stored in the corridor. Items included two computers on wheels, a trash container, and three stationary medical supply carts.

Based on surveyor observations and staff interview during the Life Safety Code tour, it was determined that the facility has failed to comply with NFPA 99 standards regarding storage requirements for cylinders containing gas on 1 of 3 patient units.

Findings are as follows:

NFPA 99 SECTION 8.3.1.11.2(h) states, "cylinder or container restraint shall meet 4.3.5.2.1 (b) 27", which states, "freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart".

Surveyor observation of the Bridge building's second floor soiled utility room located on the PACU on 11/30/10 at 9:28AM, found one nitrous oxide F size tank (40 cubic feet) which was free standing and was not secured by either a chain or a stand.

When questioned during an interview that immediately followed, the Manager of Utility Operations and Maintenance indicated this tank should have been securely stored at the third floor storage area.

Based on surveyor observation, it was determined that the facility failed to provide protection of medical gas storage in accordance with NFPA 99 Section 8.3.1.11.2(h).

Findings are as follows:

NFPA 99 Section 8.3.1.11.2(h) states, " cylinder or container restraints shall meet 4.3.5.2.1.27 " , which states, " free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart " .

During the life safety code tour on 12/2/10 at 10:30AM, accompanied by the Maintenance Director, it was revealed that two oxygen cylinders and four acetylene cylinders were unsecured in the central area of the floor located on the sub-basement level of the facility.

This Standard is not met as evidence by:

Based on observation, the facility failed to maintain clearance with heating equipment from combustible materials according to the manufacturer's specification.

Findings are as follows:

LSC Section 39.5.1. states:

"Heating, ventilating, and air conditioning equipment shall comply with the provisions of Section 9.2 and in accordance with the manufacturer's specification."

During a Life Safety Code tour of 111 Plain Street on 11/30/10, observation of the lower level mechanical room revealed that several cardboard boxes containing rolls of toilet paper were stored against (zero clearance) a gas heating unit.

This Standard is also not met as evidenced by:

Section 7.1.3.2.3 states:

"An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit."

Based on a Life Safety Code tour at 70 Catamore Boulevard on 12/1/10, two liquid oxygen dewars (containers) were observed located within the exit access corridor. Interview with the facility staff revealed that the liquid oxygen containers were routinely stored in the corridor.