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Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2.

Findings include:

A. Portions of the steel structure were observed that could not be determined to be fireproofed in a manner which is consistent with the designated building construction type.
1. A series of structural components were observed at the North Building Mechanical Penthouse. These structural components include an unprotected steel shelf or other angle, a series of steel roof joists, steel tube columns, and steel h-shape columns, all of which are covered with damaged lath and plaster.

a. During an interview held at the site on the morning of April 6, 2010, the provider's Life Safety Consultant was not able to identify UL Design or the fire resistance rating for any of the structural components listed.

b. The lath and plaster which covers the structural steel components was observed to be damaged, thus compromising any intended fire resistance rating provided by the lath and plaster.

2. A series of steel shelf or other angles were observed, in the 1990 Building Second Floor Mechanical Room, that are not covered with any fireproofing material. During an interview held at the site on the afternoon of Aril 6, 2010, the provider's Life Safety Consultant was not able to confirm the UL Design or the intended fire resistance rating for the steel angles.

Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. The following conditions were observed at the North Building Mechanical Penthouse:
1. Pipe penetrations were observed through the floor, in the northeast corner of the Penthouse, which are not sealed against the passage of fire as enquired by 8.2.3.2.4.2.

2. The opening to the abandoned Dumbwaiter shaft was observed to be open to the Penthouse as prohibited by 19.3.1.1. and 8.2.5.

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.

Findings include:

A. The door to the 1980 Building Third Floor Soiled Utility Room was observed to be held open, as prohibited by 19.3.2.1. and 8.2.3.2.3.1(1), because it binds on the floor.

B. Doors to hazardous areas were observed that are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1(1). Locations observed include:
1. The door to the North Building Second Floor Pharmacy IV Fluid Storage Room.
2. The 3/4 hour fire rated door from the 1980 Building First Floor Kitchen to the adjacent Servery.
3. The North Building First Floor Paper Storage Room.

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.

Findings include:

A. The floor of the 1980 Building East Exit Stair Roof Level landing was observed to be deteriorated and not level. The landing floor thus does not comply with 7.1.6.3.

Based on random observation during the survey walk-through, staff interview, and document review, not all emergency lighting is maintained in accordance with 7.9.

Findings include:

A. During a review of the facility's building systems test records, it was determined that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3. During an interview held in the South Building Second Floor Conference Room on the morning of April 7, 2010, the provider's Chief Engineer confirmed this finding.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. The exit signs throughout the North Building were observed to be single lamp fixtures as prohibited by 7.10.5.2. and 7.8.1.4.

Based on staff interview and random observation during the survey walk-through, as well as document review, the facility's written plan for the protection of patients is not consistently followed as required by 19.7.1.1.

Findings include:

A. During an interview held in the South Building Second Floor Conference Room on the morning of April 7, 2010, the provider's Assistant Administrator confirmed that a fire had occurred at the facility on Monday, March 1, 2010, at approximately 4:25 PM. He presented a copy of an Inter-Office Memorandum, prepared by the facility's Safety Director and dated March 9, 2010, in which the fire was described as a minor electrical fire in Patient Room 315. According to the Memorandum, the room was occupied at the time but no patients, visitors, or staff had been injured, and the patient had been evacuated to an adjacent room.

1. The Memorandum includes the statement that "The nursing staff followed the 'RACE' method reasonably well; however, the fire alarm was not pulled in a timely manner. The Fire Department was not notified of a fire within the building until over an hour after the fire, at which time the alarm was finally pulled."

2. During the interview, the provider's Assistant Administrator was not able to provide documentation of any staff training with resepct to fire incident response following the March 1, 2010 fire.

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.

Findings include:

A. Exit doors from building stories or fire compartments were observed that lack fire alarm pull stations within 5'-0" of the door as required by NFPA 72 1999 2-8.2.2. Locations observed include (all 1980 Building West Exit Stair):

1. Fifth Floor.

2. Fourth Floor.

3. Third Floor.

4. Second Floor.

By direct observation the surveyor find the facility failed to provide:

Electronic monitoring of the water supply valves for the fire pump.

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A.

Findings include:

A. Because a ventilation shaft is open to the North Building Mechanical Penthouse, the Penthouse constitutes a portion of that shaft. Combustible materials were observed being stored in the Mechanical Penthouse as prohibited by Subpart (7) to NFPA 90A 1999 3-4.3.3.



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By direct observation the facility failed to provide:

Identification of service openings for installed fire dampers.
(NFPA 90A, 1999, 2-3.4.2)

Based on direct observation, the facility failed to provide:

In the Emergency Department for rooms 1 - 6, separation of the medical gas zone control valves by means of a intervening corridor wall from supplied outlets and inlets.( NFPA 99, 1999, 4-3.1.2.3 (d)

Based on random observation during the survey walk-through, the building's emergency generators are not installed and maintained in accordance with NFPA 99.

Findings include:

A. The door to the room housing the First Floor West Emergency Generator was observed to lack a minimum 1-1/2 hour fire resistance rating required by NFPA 99 1999 3-4.1.1.6.(a), NFPA 110 1999 5-2.1. and 8.2.3.2.3.1.(1).

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, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. The Stage I Recovery Bays in the 1980 Building Second Floor Post Acute Care Unit (PACU), which constitute critical care patient beds, were observed to not be provided with a minimum of 6 electrical receptacles as required by NFPA 70 1999 517-19(b).

B. Critical care patient beds were observed at which electrical receptacles served by the building emergency electrical system are not labeled as to panel and circuit number as required by NFPA 70 1999 517-19(a). Locations observed include:

1. 1980 Building Second Floor:
a. Operating Rooms.

b. PACU Stage I Recovery Bays.

2. 1990 Building:
a. Second Floor Intensive Care Unit Patient Sleeping Rooms.

b. First Floor Emergency Department Treatment Bays.

C. An electrical extension cord ( a surge protector with plugs in all receptacles) was observed in use, in the 1980 Building Third Floor Soiled Utility Room, as prohibited by NFPA 70 1999 240-4 regarding wire size and NFPA 70 1999 305-3 regarding duration of use.

Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2.

Findings include:

A. Portions of the steel structure were observed that could not be determined to be fireproofed in a manner which is consistent with the designated building construction type.
1. A series of structural components were observed at the North Building Mechanical Penthouse. These structural components include an unprotected steel shelf or other angle, a series of steel roof joists, steel tube columns, and steel h-shape columns, all of which are covered with damaged lath and plaster.

a. During an interview held at the site on the morning of April 6, 2010, the provider's Life Safety Consultant was not able to identify UL Design or the fire resistance rating for any of the structural components listed.

b. The lath and plaster which covers the structural steel components was observed to be damaged, thus compromising any intended fire resistance rating provided by the lath and plaster.

2. A series of steel shelf or other angles were observed, in the 1990 Building Second Floor Mechanical Room, that are not covered with any fireproofing material. During an interview held at the site on the afternoon of Aril 6, 2010, the provider's Life Safety Consultant was not able to confirm the UL Design or the intended fire resistance rating for the steel angles.

Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. The following conditions were observed at the North Building Mechanical Penthouse:
1. Pipe penetrations were observed through the floor, in the northeast corner of the Penthouse, which are not sealed against the passage of fire as enquired by 8.2.3.2.4.2.

2. The opening to the abandoned Dumbwaiter shaft was observed to be open to the Penthouse as prohibited by 19.3.1.1. and 8.2.5.

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.

Findings include:

A. The door to the 1980 Building Third Floor Soiled Utility Room was observed to be held open, as prohibited by 19.3.2.1. and 8.2.3.2.3.1(1), because it binds on the floor.

B. Doors to hazardous areas were observed that are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1(1). Locations observed include:
1. The door to the North Building Second Floor Pharmacy IV Fluid Storage Room.
2. The 3/4 hour fire rated door from the 1980 Building First Floor Kitchen to the adjacent Servery.
3. The North Building First Floor Paper Storage Room.

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.

Findings include:

A. The floor of the 1980 Building East Exit Stair Roof Level landing was observed to be deteriorated and not level. The landing floor thus does not comply with 7.1.6.3.

Based on random observation during the survey walk-through, staff interview, and document review, not all emergency lighting is maintained in accordance with 7.9.

Findings include:

A. During a review of the facility's building systems test records, it was determined that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3. During an interview held in the South Building Second Floor Conference Room on the morning of April 7, 2010, the provider's Chief Engineer confirmed this finding.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. The exit signs throughout the North Building were observed to be single lamp fixtures as prohibited by 7.10.5.2. and 7.8.1.4.

Based on staff interview and random observation during the survey walk-through, as well as document review, the facility's written plan for the protection of patients is not consistently followed as required by 19.7.1.1.

Findings include:

A. During an interview held in the South Building Second Floor Conference Room on the morning of April 7, 2010, the provider's Assistant Administrator confirmed that a fire had occurred at the facility on Monday, March 1, 2010, at approximately 4:25 PM. He presented a copy of an Inter-Office Memorandum, prepared by the facility's Safety Director and dated March 9, 2010, in which the fire was described as a minor electrical fire in Patient Room 315. According to the Memorandum, the room was occupied at the time but no patients, visitors, or staff had been injured, and the patient had been evacuated to an adjacent room.

1. The Memorandum includes the statement that "The nursing staff followed the 'RACE' method reasonably well; however, the fire alarm was not pulled in a timely manner. The Fire Department was not notified of a fire within the building until over an hour after the fire, at which time the alarm was finally pulled."

2. During the interview, the provider's Assistant Administrator was not able to provide documentation of any staff training with resepct to fire incident response following the March 1, 2010 fire.

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.

Findings include:

A. Exit doors from building stories or fire compartments were observed that lack fire alarm pull stations within 5'-0" of the door as required by NFPA 72 1999 2-8.2.2. Locations observed include (all 1980 Building West Exit Stair):

1. Fifth Floor.

2. Fourth Floor.

3. Third Floor.

4. Second Floor.

By direct observation the surveyor find the facility failed to provide:

Electronic monitoring of the water supply valves for the fire pump.

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A.

Findings include:

A. Because a ventilation shaft is open to the North Building Mechanical Penthouse, the Penthouse constitutes a portion of that shaft. Combustible materials were observed being stored in the Mechanical Penthouse as prohibited by Subpart (7) to NFPA 90A 1999 3-4.3.3.



14416


By direct observation the facility failed to provide:

Identification of service openings for installed fire dampers.
(NFPA 90A, 1999, 2-3.4.2)

Based on direct observation, the facility failed to provide:

In the Emergency Department for rooms 1 - 6, separation of the medical gas zone control valves by means of a intervening corridor wall from supplied outlets and inlets.( NFPA 99, 1999, 4-3.1.2.3 (d)

Based on random observation during the survey walk-through, the building's emergency generators are not installed and maintained in accordance with NFPA 99.

Findings include:

A. The door to the room housing the First Floor West Emergency Generator was observed to lack a minimum 1-1/2 hour fire resistance rating required by NFPA 99 1999 3-4.1.1.6.(a), NFPA 110 1999 5-2.1. and 8.2.3.2.3.1.(1).

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, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. The Stage I Recovery Bays in the 1980 Building Second Floor Post Acute Care Unit (PACU), which constitute critical care patient beds, were observed to not be provided with a minimum of 6 electrical receptacles as required by NFPA 70 1999 517-19(b).

B. Critical care patient beds were observed at which electrical receptacles served by the building emergency electrical system are not labeled as to panel and circuit number as required by NFPA 70 1999 517-19(a). Locations observed include:

1. 1980 Building Second Floor:
a. Operating Rooms.

b. PACU Stage I Recovery Bays.

2. 1990 Building:
a. Second Floor Intensive Care Unit Patient Sleeping Rooms.

b. First Floor Emergency Department Treatment Bays.

C. An electrical extension cord ( a surge protector with plugs in all receptacles) was observed in use, in the 1980 Building Third Floor Soiled Utility Room, as prohibited by NFPA 70 1999 240-4 regarding wire size and NFPA 70 1999 305-3 regarding duration of use.