HospitalInspections.org

Based on observations during the survey walk, the facility failed to maintain the fire resistance rating of a 2 hour fire barrier.

Building #2 survey walk, the inspectors observed the following issues with 2 hour walls:
1. There was a pipe penetration in the wall between the doctor ' s parking and the mechanical room
2. There were penetrations in the wall between the doctor ' s parking and the ATS and switch gear rooms.
3. The door from the Kitchen to the stair does not close.

Based on observations during the survey walk, the facility failed to maintain the fire resistance rating of a 2 hour fire barrier.

Building #5 survey walk, the inspectors observed the following issues with 2 hour walls:
1. On the first floor there was a penetration of the 2 hour wall at the Women ' s Center above a door on the south side of the center
2. On the first floor there was a door to the area below the MRI room that served a storage room that was not part of the hospital that did not have a 90 minute rated fire door.

Based on observations during the survey walk of Building #2, the facility failed to maintain the fire rating of the structure. The inspectors observed that there were penetrations in the floor/ceiling assembly in two electrical rooms on the second floor on the west side of Zone 2H.

Based on observations during the survey walk of Building #1, the facility failed to assure the integrity of the corridor. The inspectors observed:
1. No door closer for the corridor door to the linen room located on the east side of the North corridor on Level 5 of Building ' B ' .
2. A second door (with no door closer) leads from this room to an adjacent nurse station. The nurse station is designed such that it is open to the same north corridor, and therefore the second door also is required to have a door closer.

Based on observations during the survey walk, the facility failed to provide adequate vertical opening enclosure.

Based on observations during the survey walk of Building #1, the exit stair from the sub-basement level to the outside of the building had a prohibited penetration. There was an oxygen pipe running through it

Based on observations during the survey walk, the facility failed to provide adequate vertical opening enclosure.

Building #2 survey walk, the inspectors observed that there was a vertical opening in a basement mechanical room that opened to the floor above that did not have a rated door and closure for the mechanical room.

Based on observations during the survey walk, the facility failed to provide adequate vertical opening enclosure.

Building #5 survey walk, the inspectors observed the following issues with the stairs.
1. 3rd floor stair #3 West, the door did not latch on its own
2. 3rd floor stair #1, the door not latch on its own
3. 1st floor mechanical room, door 1D1, to a vertical chase door did not latch on own

Based on observations during the survey walk, the facility failed to maintain smoke barriers.

Building #1 survey walk, the inspectors observed penetrations in the following locations:
1. Between C and D buildings by the Bio-Medical Office in the basement
2. On the 6th floor at door 28D,

Based on observations during the survey walk, the facility failed to maintain smoke barriers.

Building #2 survey walk, the inspectors observed penetrations in the following locations:
1. In the basement in PCU south corridor by service elevator 6-8;
2. 2nd floor by the Pharmacy;
3. Basement at dietary entry by SPD;
4. Basement at dining room #1 and #2;
5. 1st floor on the southern most east/west corridor from Zone 1M into Zone 1N;
6. On the south side of cath. Lab #1;
7. By the east stair of the original building;
8. Smoke barrier outside Dining #1;
9. Double egress outside Pharmacy;
10. Above double egress doors across from Lab entering into Smoke compartment 1F and;
11. Above double egress doors entering into Smoke compartment 2A.

Based on observations during the survey walk, the facility failed to maintain smoke barriers.

Building #5 survey walk, the inspectors observed penetrations in the following locations:
1. Smoke barrier above door 1GB2
2. Smoke barrier above door 1B-FIRE-4B
3. Smoke barrier above door FIR-1F2
4. Interstitial space at walkway barrier of Smoke Compartment 2K
5. Above cross corridor doors on east side of Zone 5A
6. Above cross corridor doors on east side of lobby between Zone 2C and 2F
7. Above door between Zone 2D and 2B adjacent to the courtyard
8. Above the cross corridor door between Zone 1A and 1B
9. Above cross corridor door between zone 1B and 1C
10. Gaps at the edge of the barrier at the following locations
a. top of barrier above door SMK-5C-1A
b. top of barrier between imaging offices and waiting room
c. the smoke barrier above door 1AFIRE6A,

Based on observations during the survey walk, the facility failed to provide an acceptable separation for hazardous areas.

Building #2 survey walk, the inspectors observed the following issues:
1. On the 1st floor a supply room at the northeast portion of the building did not have a labeled door; in the post 2003 portion of the facility
2. The clean utility in the PACU did not have a labeled door, in the post 2003 portion of the facility;
3. Dietary storage on the 2nd floor did not have a closer in the post 2003 portion of the facility

Based on observations during the survey walk, the facility failed to provide an acceptable separation for hazardous areas.

Building #3 survey walk, the inspectors observed the door to the soiled utility room in the orthopedic wing on the first floor, constructed in 1985, did not have a 45 minute fire rating label.

Based on observations during the survey walk, the facility failed to provide an acceptable separation for hazardous areas.

Building #5 survey walk, the inspectors observed the following issues:
1. The following doors did not have closers: 1) pharmacy store room door in Basement, 2) door to Rad room #4, being used as storage, 3) office next to director ' s office being used as storage, 4) the abandoned toilet room, now considered storage, adjacent to elevator #6 in the basement
2. A door did not latch at the following locations: 1) 3rd floor Equipment Room by Elevator Lobby #2, 2) kitchen electrical room
3. The door latch had tape over it to prevent the door from latching at 2nd floor biohazard room.
4. The mechanical rooms were being used as storage of large quantities of filters in cardboard boxes. These rooms shall be treated as hazardous areas. Verify that all doors have closers and latch on their own.

Based on observations during the survey walk of Building #1, the facility failed to provide an adequate stair enclosure. The fire door to the stair by O.R. #6 did not close properly.

Based on observations during the survey walk of Building #5, the facility failed to provide adequate lighting at exits.
The inspectors observed that there were not two sources of illumination at exterior exits in the following locations.
1. The exit adjacent to the storage space below the MRI.
2. The southern most stair in Zone 1F.

Based on observations during the survey walk of Building #2, the facility failed to provide an adequate fire alarm. The inspectors observed that there was a broken heat detector in the elevator equipment room.

Based on observations during the survey walk of Building #5, the facility failed to provide acceptable smoke detectors. The inspectors observed that smoke detectors were not functional as evidenced by observance of smoke detector M1-71 and heat detector M1-72 located in Equipment room for Elevator #6 being covered with plastic.

Based on observations during the survey walk, the facility failed to provide an acceptable sprinkler system.

Building #1 survey walk, the inspectors observed the
1. Sprinkler system valves located in the sub-basement and basement levels of the facility did not have permanent labels indicating the function of each valve.
2. Storage that was above the 18 inch plane that starts from the bottom of the sprinkler head and goes downward. Items may not be stored above this plane because this can interfere with the sprinkler coverage. This deficiency was observed on Level 7 of Building ' B ' in the following rooms:
1) The central supply room (accessible from the east corridor and located immediately adjacent to Building ' D '
2) The larger central supply room (accessible from the east corridor where this corridor turns at 45 degree angle in floor plan).

Based on observations during the survey walk, the facility failed to provide an acceptable sprinkler system.

Building #2 survey walk, the inspectors observed the following issues:
1. At the pharmacy there were items stored above the 18 inch plane defined by the zone below the sprinkler shields away from storage on the walls;
2. A sprinkler head in the basement Mechanical room is embedded in the duct insulation.

Based on observations during the survey walk, the facility failed to provide an acceptable sprinkler system.

Building #5 survey walk, the inspectors observed the following issues:
1. The sprinkler heads in the staff locker room were located only 6 inches from an 18 " deep furr-down. Lockers that were located under furr-down had been removed.
2. Escutcheons were missing from sprinkler heads in rooms 2510 and 2511. Escutcheons are part of the listed assembly per 1999 NFPA 13 §3-2.7.2.
3. The following rooms did not have a sprinkler head: 1) the abandoned toilet room, now considered storage, adjacent to elevator #6 in the basement, 2) biohazard room in Emergency Department (ED), 3) kitchen freezer

Based on observations during the survey walk of Building #1, the facility failed to maintain coverage of the sprinkler system.
The inspectors observed:
1. A sprinkler head located in the telephone room near the exit stair / elevators on Level 7 of Building ' B ' had been coated with what appeared to be white paint.
2. The escutcheon portion of the listed sprinkler assembly was missing.

Based on observations during the survey walk of Building #5, the facility failed to provide an adequate fire extinguisher. The inspectors observed a sign indicating a fire extinguisher location that did not have the extinguisher located there.

Based on observations during the survey walk, the facility failed to provide adequate medical gas storage and provide a medical gas system compliant with NFPA 99

Building #1 survey walk, the inspectors observed the following issues:
1. In the B wing where operatories 4 through 12 are located there were numerous small closets with a nitrous oxide cylinder immediately adjacent to a transform located below 5 ' from the finished floor,
2. The exterior medical gas enclosure contain nitrous oxide and did not have the proper signage that should be as follows:

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

3. There was a car parked at a distance of less than 10 feet from the bulk oxygen tank. - NFPA 50, 2001, 2.2.12, and
4. There was a zone shut off valve in the space that it serves in SICU on the 6th floor. NFPA 99, 1999, 4-3.1.2.3(d).

Based on observations during the survey walk, the facility failed to provide adequate medical gas storage and provide a medical gas system compliant with NFPA 99

Building #2 survey walk, the inspectors observed that there were flammable gases stored with the medical gas enclosure. " Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials. " - NFPA 99, 1999, 4-3.1.1.2(a)5.

Based on observations during the survey walk of Building #2, the facility failed to provide an acceptable separation between medical gas outlets and the zone control valves. The inspectors observed that there was no separating wall between the outlets and the med gas valves inside the NICU.

Based on observations during the survey walk of Building #1, the facility failed to provide a complaint electrical room. Rooms with transformers larger than 112. kVA shall have a 1 hour fire rating as giving by the following. " Individual dry-type transformers of more than 112.5 kVA rating shall be installed in a transformer room of fire-resistant construction. Unless specified otherwise in this article, the term fire resistant means a construction having a minimum fire rating of 1 hour. " - NFPA 70, 450.21(B). Exception No. 1: Transformers with Class 155 or higher insulation systems and separated from combustible material by a fire-resistant, heat-insulating barrier or by not less than 6 ft horizontally and 12 ft vertically. Exception No. 2: Transformers with Class 155 or higher insulation systems and completely enclosed except for ventilating openings. (Note: the two exceptions were revised in the 1999 code to use the Class 155 rating that provides a more complete reference than a simple temperature rise.) The main electrical room in the basement had doors that were not 45 minute fire rated doors or better. Verify the Class 155 or better rating of the transformers.

Based on observations during the survey walk of Building #5, the facility failed to maintain storage areas.
The inspectors observed the following:
1. The facility failed to keep storage of materials the correct distance below the sprinkler heads as evidenced by storage items on the center shelves of the basement crawl space storage were being stored closer than 18 " below the sprinkler head.
2. The facility failed to provide an acceptable clearance around the bulk oxygen tank. There was parking of motor vehicles immediately adjacent to the bulk oxygen tank. The minimum required distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 feet by NFPA 50, 2.2.12.
3. An exit sign was not illuminated in the mechanical room on the 1st floor. - NFPA 101, 7.10.

Based on the review of the records for Building #2, the facility failed to provide documentation of receptacle testing. Testing and inspection of receptacles for continuity of grounding, physical integrity of the receptacle, correct polarity, and retention force of the grounding blade are required annually for general care areas, and semi-annually for critical care areas. - NFPA 99, 1999: 3-3.3.3.and 7-6.2.1.2.

Based on observations during the survey walk of Building #2, the facility failed to provide a secondary generator alarm. The facility only had one generator alarm located at dispatch and none in the maintenance area for the operating personnel. " A remote annunciator, storage battery-powered, shall be provided to operate outside the generating room in a location readily observed by operating personnel at a regular work station. Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. " - NFPA 99, 1999: 3-4.1.1.15

Based on observations during the survey walk, the facility failed to provide a proper type I Essential electrical system.

Building #1 survey walk, the inspectors observed the following issues:
1. The emergency generator locations must have lighting on the life safety branch, an electrical receptacle on the life safety branch, and a battery backup light with 90 minutes of life also on the life safety branch. This was not clear in many of the locations. Specifically: 1) generator #6 did not have a free receptacle, 2) generators 3, 4, and 10 did not have life safety general lighting, 3) generator #7 did not have life safety general lighting.
2. " A remote annunciator, storage battery-powered, shall be provided to operate outside the generating room in a location readily observed by operating personnel at a regular work station. Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. " - NFPA 99, 1999: 3-4.1.1.15. The facility only had one generator alarm located at maintenance and none in the PBX area. Only generators 7 and 10 were alarmed at maintenance. Other generators did not have a remote alarm.
3. In the basement not all the EES panels were labeled according to the branch they serve.
4. Cover Plates: In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates, permanent adhesive engraved laminated labels or labels covered with clear coating. The circuit and panel number was not indicated on the receptacle covers in the following locations:: 1) SICU, 2) PACU, and 3) Operating Rooms.. See following definition of critical areas. Critical care areas are defined as special care units, intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, operating rooms, post-anesthesia recovery rooms, emergency departments, and similar areas in which patients are intended to be subjected to invasive procedures and connected to line-operated, patient-care-related electrical appliances, re NFPA 99, 2002, 3.3.135.2.
5. Some of the emergency generators did not have alarm annunciators.
6. The generators that did have alarms had them located only in the maintenance shop which is not a continuously monitored location.
7. Some emergency panels on the critical branch of the EES were not labeled ' CRITICAL ' to identify them as components of that branch of the system. These panels included ' E3CA ' , ' B3CR ' , ' BIDFCR ' , all located on the third floor. There was also an equipment branch panel ' E3E ' on the third floor that was not labeled ' EQUIPMENT ' .
8. There was an automatic transfer switch in the basement that was not labeled ' EQUIPMENT ' to identify it as a component of the equipment branch of the EES.
9. Emergency generator #6 did not have an emergency receptacle at that location.
10. There were multiple generator sets serving the hospital. All of the generator set locations had battery powered emergency lighting, but none had lighting on the life safety branch of the EES.
11. There were two medication refrigerators at the first floor emergency department that were plugged into normal power receptacles, instead of emergency receptacles.
12. The laboratory had equipment plugged into white power strips. It was not clear whether these strips were being powered from the normal power system or the emergency branch of the EES.

Based on observations during the survey walk, the facility failed to provide a proper type I Essential electrical system.

Building #2 survey walk, the inspectors observed the following issues:
1. On the 1st floor in the electrical room near Cath Lab #2 Equipment Room panel LSB is a life safety panel and has a circuit for Code Blue. This must be move to a critical panel. Only those loads designated by NFPA 99 and 70 are allowed in a life safety panel.
2. Cover Plates: In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates, permanent adhesive engraved laminated labels or labels covered with clear coating. The circuit and panel number was not indicated on the receptacle covers in the following locations:: 1) O.R.s 1 through 8, 2) special procedure rooms for angio and cysto, 3) G.I. recovery. See following definition of critical areas. Critical care areas are defined as special care units, intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, operating rooms, post-anesthesia recovery rooms, emergency departments, and similar areas in which patients are intended to be subjected to invasive procedures and connected to line-operated, patient-care-related electrical appliances, re NFPA 99, 2002, 3.3.135.2.)
3. Acceptable wiring: Junction boxes did not have covers or were not closed in the following areas:
i. Lab storage by DeIonized water;
ii. in plenum above cross corridor doors between Smoke Zones 1A/1F and 1C/1E
iii. in plenum above cross corridor doors between Smoke Zone 1J and 1I
iv. in plenum above cross corridor doors between Smoke Zone 1J and 1N
v. in plenum above cross corridor doors between Smoke Zone 2B and 2E
vi. in plenum above cross corridor doors at north south corridor between Smoke Zone 4A and 4B.

Based on observations during the survey walk, the facility failed to provide a proper type I Essential electrical system.

Building #3 survey walk, the inspectors observed the following issues:
1. There was no emergency lighting in the endoscopy recovery room.
2. There was no emergency lighting in the endoscopy procedure room.
3. There were no emergency receptacles in eight patient rooms on the ground floor.
4. no circuit and panel number indicated on the receptacle covers in two OB department ' s operating rooms:

Based on observations during the survey walk, the facility failed to provide a proper type I Essential electrical system.

Building #5 survey walk, the inspectors observed the following issues:
1. The panel for Generator #1 indicates it is fed from the Critical Branch. NFPA 99 requires the generator battery charger, lights, and outlet to be powered by the Life Safety Branch. Generator accessory power source branch could not be identified for generator #3.
2. Cover Plates: In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates, permanent adhesive engraved laminated labels or labels covered with clear coating. The circuit and panel number was not indicated on the receptacle covers in the following locations: 1) ED, and 2) other miscellaneous areas. See following definition of critical areas. Critical care areas are defined as special care units, intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, operating rooms, post-anesthesia recovery rooms, emergency departments, and similar areas in which patients are intended to be subjected to invasive procedures and connected to line-operated, patient-care-related electrical appliances, re NFPA 99, 2002, 3.3.135.2.)
3. The fire alarm control panel must have a label indicating the panel and breaker supplying power and the breaker in the electrical panel must have a label adjacent to the breaker indicating " FIRE ALARM CIRCUIT CONTROL " and the breaker shall be colored red. The breaker for the main FACP was not colored red.
4. The EES panels must be labeled according to the branch they serve. This must be addressed in the following locations: 1) on the 3rd floor at the Acute Rehab, 2) the electrical room at the Cath Lab, 3) pharmacy electrical room, 4) kitchen electrical room.

Based on observations during the survey walk of Building #5, the facility failed to provide acceptable electrical wiring and equipment in accordance with NFPA 70, the National Electrical Code.
The inspectors observed the following:
1. Junction boxes did not have covers or were not closed in the plenum space above the following doors: 1) lobby doors for elevators 3 and 4 on the 3rd floor, 2) door SMK-2A-3
2. Junction boxes did not have covers in the following rooms: 1) Mechanical room in the Basement, 2) Lab breakroom,

Based on observations during the survey walk, the facility failed to provide an adequate installation of alcohol based hand rubs.

Building #1 survey walk, the inspectors observed that there were alcohol based hand rubs over electrical outlets or switches in the Recovery Area, beds 7 & 10.

Based on observations during the survey walk, the facility failed to provide an adequate installation of alcohol based hand rubs.

Building #2 survey walk, the inspectors observed the alcohol based hand rubs were within 6 inches of an electrical outlet or switch at:
1. 2nd floor lactation consult room;
2. 2nd floor meds room for post partum;
3. 2nd floor environmental services;
4. 1st floor clean utility in PACU;
5. 1st floor MRI control room;

Based on observations during the survey walk, the facility failed to provide an adequate installation of alcohol based hand rubs.

Building #5 survey walk, the inspectors that there was an alcohol based hand rub in the SPD area that was less than 6 inches laterally from an electrical outlet or switch.

Based on observations during the survey walk, the facility failed to maintain the fire resistance rating of a 2 hour fire barrier.

Building #2 survey walk, the inspectors observed the following issues with 2 hour walls:
1. There was a pipe penetration in the wall between the doctor ' s parking and the mechanical room
2. There were penetrations in the wall between the doctor ' s parking and the ATS and switch gear rooms.
3. The door from the Kitchen to the stair does not close.

Based on observations during the survey walk, the facility failed to maintain the fire resistance rating of a 2 hour fire barrier.

Building #5 survey walk, the inspectors observed the following issues with 2 hour walls:
1. On the first floor there was a penetration of the 2 hour wall at the Women ' s Center above a door on the south side of the center
2. On the first floor there was a door to the area below the MRI room that served a storage room that was not part of the hospital that did not have a 90 minute rated fire door.

Based on observations during the survey walk of Building #2, the facility failed to maintain the fire rating of the structure. The inspectors observed that there were penetrations in the floor/ceiling assembly in two electrical rooms on the second floor on the west side of Zone 2H.

Based on observations during the survey walk of Building #1, the facility failed to assure the integrity of the corridor. The inspectors observed:
1. No door closer for the corridor door to the linen room located on the east side of the North corridor on Level 5 of Building ' B ' .
2. A second door (with no door closer) leads from this room to an adjacent nurse station. The nurse station is designed such that it is open to the same north corridor, and therefore the second door also is required to have a door closer.

Based on observations during the survey walk, the facility failed to provide adequate vertical opening enclosure.

Based on observations during the survey walk of Building #1, the exit stair from the sub-basement level to the outside of the building had a prohibited penetration. There was an oxygen pipe running through it

Based on observations during the survey walk, the facility failed to provide adequate vertical opening enclosure.

Building #2 survey walk, the inspectors observed that there was a vertical opening in a basement mechanical room that opened to the floor above that did not have a rated door and closure for the mechanical room.

Based on observations during the survey walk, the facility failed to provide adequate vertical opening enclosure.

Building #5 survey walk, the inspectors observed the following issues with the stairs.
1. 3rd floor stair #3 West, the door did not latch on its own
2. 3rd floor stair #1, the door not latch on its own
3. 1st floor mechanical room, door 1D1, to a vertical chase door did not latch on own

Based on observations during the survey walk, the facility failed to maintain smoke barriers.

Building #1 survey walk, the inspectors observed penetrations in the following locations:
1. Between C and D buildings by the Bio-Medical Office in the basement
2. On the 6th floor at door 28D,

Based on observations during the survey walk, the facility failed to maintain smoke barriers.

Building #2 survey walk, the inspectors observed penetrations in the following locations:
1. In the basement in PCU south corridor by service elevator 6-8;
2. 2nd floor by the Pharmacy;
3. Basement at dietary entry by SPD;
4. Basement at dining room #1 and #2;
5. 1st floor on the southern most east/west corridor from Zone 1M into Zone 1N;
6. On the south side of cath. Lab #1;
7. By the east stair of the original building;
8. Smoke barrier outside Dining #1;
9. Double egress outside Pharmacy;
10. Above double egress doors across from Lab entering into Smoke compartment 1F and;
11. Above double egress doors entering into Smoke compartment 2A.

Based on observations during the survey walk, the facility failed to maintain smoke barriers.

Building #5 survey walk, the inspectors observed penetrations in the following locations:
1. Smoke barrier above door 1GB2
2. Smoke barrier above door 1B-FIRE-4B
3. Smoke barrier above door FIR-1F2
4. Interstitial space at walkway barrier of Smoke Compartment 2K
5. Above cross corridor doors on east side of Zone 5A
6. Above cross corridor doors on east side of lobby between Zone 2C and 2F
7. Above door between Zone 2D and 2B adjacent to the courtyard
8. Above the cross corridor door between Zone 1A and 1B
9. Above cross corridor door between zone 1B and 1C
10. Gaps at the edge of the barrier at the following locations
a. top of barrier above door SMK-5C-1A
b. top of barrier between imaging offices and waiting room
c. the smoke barrier above door 1AFIRE6A,

Based on observations during the survey walk, the facility failed to provide an acceptable separation for hazardous areas.

Building #2 survey walk, the inspectors observed the following issues:
1. On the 1st floor a supply room at the northeast portion of the building did not have a labeled door; in the post 2003 portion of the facility
2. The clean utility in the PACU did not have a labeled door, in the post 2003 portion of the facility;
3. Dietary storage on the 2nd floor did not have a closer in the post 2003 portion of the facility

Based on observations during the survey walk, the facility failed to provide an acceptable separation for hazardous areas.

Building #3 survey walk, the inspectors observed the door to the soiled utility room in the orthopedic wing on the first floor, constructed in 1985, did not have a 45 minute fire rating label.

Based on observations during the survey walk, the facility failed to provide an acceptable separation for hazardous areas.

Building #5 survey walk, the inspectors observed the following issues:
1. The following doors did not have closers: 1) pharmacy store room door in Basement, 2) door to Rad room #4, being used as storage, 3) office next to director ' s office being used as storage, 4) the abandoned toilet room, now considered storage, adjacent to elevator #6 in the basement
2. A door did not latch at the following locations: 1) 3rd floor Equipment Room by Elevator Lobby #2, 2) kitchen electrical room
3. The door latch had tape over it to prevent the door from latching at 2nd floor biohazard room.
4. The mechanical rooms were being used as storage of large quantities of filters in cardboard boxes. These rooms shall be treated as hazardous areas. Verify that all doors have closers and latch on their own.

Based on observations during the survey walk of Building #1, the facility failed to provide an adequate stair enclosure. The fire door to the stair by O.R. #6 did not close properly.

Based on observations during the survey walk of Building #5, the facility failed to provide adequate lighting at exits.
The inspectors observed that there were not two sources of illumination at exterior exits in the following locations.
1. The exit adjacent to the storage space below the MRI.
2. The southern most stair in Zone 1F.

Based on observations during the survey walk of Building #2, the facility failed to provide an adequate fire alarm. The inspectors observed that there was a broken heat detector in the elevator equipment room.

Based on observations during the survey walk of Building #5, the facility failed to provide acceptable smoke detectors. The inspectors observed that smoke detectors were not functional as evidenced by observance of smoke detector M1-71 and heat detector M1-72 located in Equipment room for Elevator #6 being covered with plastic.

Based on observations during the survey walk, the facility failed to provide an acceptable sprinkler system.

Building #1 survey walk, the inspectors observed the
1. Sprinkler system valves located in the sub-basement and basement levels of the facility did not have permanent labels indicating the function of each valve.
2. Storage that was above the 18 inch plane that starts from the bottom of the sprinkler head and goes downward. Items may not be stored above this plane because this can interfere with the sprinkler coverage. This deficiency was observed on Level 7 of Building ' B ' in the following rooms:
1) The central supply room (accessible from the east corridor and located immediately adjacent to Building ' D '
2) The larger central supply room (accessible from the east corridor where this corridor turns at 45 degree angle in floor plan).

Based on observations during the survey walk, the facility failed to provide an acceptable sprinkler system.

Building #2 survey walk, the inspectors observed the following issues:
1. At the pharmacy there were items stored above the 18 inch plane defined by the zone below the sprinkler shields away from storage on the walls;
2. A sprinkler head in the basement Mechanical room is embedded in the duct insulation.

Based on observations during the survey walk, the facility failed to provide an acceptable sprinkler system.

Building #5 survey walk, the inspectors observed the following issues:
1. The sprinkler heads in the staff locker room were located only 6 inches from an 18 " deep furr-down. Lockers that were located under furr-down had been removed.
2. Escutcheons were missing from sprinkler heads in rooms 2510 and 2511. Escutcheons are part of the listed assembly per 1999 NFPA 13 §3-2.7.2.
3. The following rooms did not have a sprinkler head: 1) the abandoned toilet room, now considered storage, adjacent to elevator #6 in the basement, 2) biohazard room in Emergency Department (ED), 3) kitchen freezer

Based on observations during the survey walk of Building #1, the facility failed to maintain coverage of the sprinkler system.
The inspectors observed:
1. A sprinkler head located in the telephone room near the exit stair / elevators on Level 7 of Building ' B ' had been coated with what appeared to be white paint.
2. The escutcheon portion of the listed sprinkler assembly was missing.

Based on observations during the survey walk of Building #5, the facility failed to provide an adequate fire extinguisher. The inspectors observed a sign indicating a fire extinguisher location that did not have the extinguisher located there.

Based on observations during the survey walk, the facility failed to provide adequate medical gas storage and provide a medical gas system compliant with NFPA 99

Building #1 survey walk, the inspectors observed the following issues:
1. In the B wing where operatories 4 through 12 are located there were numerous small closets with a nitrous oxide cylinder immediately adjacent to a transform located below 5 ' from the finished floor,
2. The exterior medical gas enclosure contain nitrous oxide and did not have the proper signage that should be as follows:

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

3. There was a car parked at a distance of less than 10 feet from the bulk oxygen tank. - NFPA 50, 2001, 2.2.12, and
4. There was a zone shut off valve in the space that it serves in SICU on the 6th floor. NFPA 99, 1999, 4-3.1.2.3(d).

Based on observations during the survey walk, the facility failed to provide adequate medical gas storage and provide a medical gas system compliant with NFPA 99

Building #2 survey walk, the inspectors observed that there were flammable gases stored with the medical gas enclosure. " Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials. " - NFPA 99, 1999, 4-3.1.1.2(a)5.

Based on observations during the survey walk of Building #2, the facility failed to provide an acceptable separation between medical gas outlets and the zone control valves. The inspectors observed that there was no separating wall between the outlets and the med gas valves inside the NICU.

Based on observations during the survey walk of Building #1, the facility failed to provide a complaint electrical room. Rooms with transformers larger than 112. kVA shall have a 1 hour fire rating as giving by the following. " Individual dry-type transformers of more than 112.5 kVA rating shall be installed in a transformer room of fire-resistant construction. Unless specified otherwise in this article, the term fire resistant means a construction having a minimum fire rating of 1 hour. " - NFPA 70, 450.21(B). Exception No. 1: Transformers with Class 155 or higher insulation systems and separated from combustible material by a fire-resistant, heat-insulating barrier or by not less than 6 ft horizontally and 12 ft vertically. Exception No. 2: Transformers with Class 155 or higher insulation systems and completely enclosed except for ventilating openings. (Note: the two exceptions were revised in the 1999 code to use the Class 155 rating that provides a more complete reference than a simple temperature rise.) The main electrical room in the basement had doors that were not 45 minute fire rated doors or better. Verify the Class 155 or better rating of the transformers.

Based on observations during the survey walk of Building #5, the facility failed to maintain storage areas.
The inspectors observed the following:
1. The facility failed to keep storage of materials the correct distance below the sprinkler heads as evidenced by storage items on the center shelves of the basement crawl space storage were being stored closer than 18 " below the sprinkler head.
2. The facility failed to provide an acceptable clearance around the bulk oxygen tank. There was parking of motor vehicles immediately adjacent to the bulk oxygen tank. The minimum required distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 feet by NFPA 50, 2.2.12.
3. An exit sign was not illuminated in the mechanical room on the 1st floor. - NFPA 101, 7.10.

Based on the review of the records for Building #2, the facility failed to provide documentation of receptacle testing. Testing and inspection of receptacles for continuity of grounding, physical integrity of the receptacle, correct polarity, and retention force of the grounding blade are required annually for general care areas, and semi-annually for critical care areas. - NFPA 99, 1999: 3-3.3.3.and 7-6.2.1.2.

Based on observations during the survey walk of Building #2, the facility failed to provide a secondary generator alarm. The facility only had one generator alarm located at dispatch and none in the maintenance area for the operating personnel. " A remote annunciator, storage battery-powered, shall be provided to operate outside the generating room in a location readily observed by operating personnel at a regular work station. Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. " - NFPA 99, 1999: 3-4.1.1.15

Based on observations during the survey walk, the facility failed to provide a proper type I Essential electrical system.

Building #1 survey walk, the inspectors observed the following issues:
1. The emergency generator locations must have lighting on the life safety branch, an electrical receptacle on the life safety branch, and a battery backup light with 90 minutes of life also on the life safety branch. This was not clear in many of the locations. Specifically: 1) generator #6 did not have a free receptacle, 2) generators 3, 4, and 10 did not have life safety general lighting, 3) generator #7 did not have life safety general lighting.
2. " A remote annunciator, storage battery-powered, shall be provided to operate outside the generating room in a location readily observed by operating personnel at a regular work station. Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. " - NFPA 99, 1999: 3-4.1.1.15. The facility only had one generator alarm located at maintenance and none in the PBX area. Only generators 7 and 10 were alarmed at maintenance. Other generators did not have a remote alarm.
3. In the basement not all the EES panels were labeled according to the branch they serve.
4. Cover Plates: In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates, permanent adhesive engraved laminated labels or labels covered with clear coating. The circuit and panel number was not indicated on the receptacle covers in the following locations:: 1) SICU, 2) PACU, and 3) Operating Rooms.. See following definition of critical areas. Critical care areas are defined as special care units, intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, operating rooms, post-anesthesia recovery rooms, emergency departments, and similar areas in which patients are intended to be subjected to invasive procedures and connected to line-operated, patient-care-related electrical appliances, re NFPA 99, 2002, 3.3.135.2.
5. Some of the emergency generators did not have alarm annunciators.
6. The generators that did have alarms had them located only in the maintenance shop which is not a continuously monitored location.
7. Some emergency panels on the critical branch of the EES were not labeled ' CRITICAL ' to identify them as components of that branch of the system. These panels included ' E3CA ' , ' B3CR ' , ' BIDFCR ' , all located on the third floor. There was also an equipment branch panel ' E3E ' on the third floor that was not labeled ' EQUIPMENT ' .
8. There was an automatic transfer switch in the basement that was not labeled ' EQUIPMENT ' to identify it as a component of the equipment branch of the EES.
9. Emergency generator #6 did not have an emergency receptacle at that location.
10. There were multiple generator sets serving the hospital. All of the generator set locations had battery powered emergency lighting, but none had lighting on the life safety branch of the EES.
11. There were two medication refrigerators at the first floor emergency department that were plugged into normal power receptacles, instead of emergency receptacles.
12. The laboratory had equipment plugged into white power strips. It was not clear whether these strips were being powered from the normal power system or the emergency branch of the EES.

Based on observations during the survey walk, the facility failed to provide a proper type I Essential electrical system.

Building #2 survey walk, the inspectors observed the following issues:
1. On the 1st floor in the electrical room near Cath Lab #2 Equipment Room panel LSB is a life safety panel and has a circuit for Code Blue. This must be move to a critical panel. Only those loads designated by NFPA 99 and 70 are allowed in a life safety panel.
2. Cover Plates: In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates, permanent adhesive engraved laminated labels or labels covered with clear coating. The circuit and panel number was not indicated on the receptacle covers in the following locations:: 1) O.R.s 1 through 8, 2) special procedure rooms for angio and cysto, 3) G.I. recovery. See following definition of critical areas. Critical care areas are defined as special care units, intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, operating rooms, post-anesthesia recovery rooms, emergency departments, and similar areas in which patients are intended to be subjected to invasive procedures and connected to line-operated, patient-care-related electrical appliances, re NFPA 99, 2002, 3.3.135.2.)
3. Acceptable wiring: Junction boxes did not have covers or were not closed in the following areas:
i. Lab storage by DeIonized water;
ii. in plenum above cross corridor doors between Smoke Zones 1A/1F and 1C/1E
iii. in plenum above cross corridor doors between Smoke Zone 1J and 1I
iv. in plenum above cross corridor doors between Smoke Zone 1J and 1N
v. in plenum above cross corridor doors between Smoke Zone 2B and 2E
vi. in plenum above cross corridor doors at north south corridor between Smoke Zone 4A and 4B.

Based on observations during the survey walk, the facility failed to provide a proper type I Essential electrical system.

Building #3 survey walk, the inspectors observed the following issues:
1. There was no emergency lighting in the endoscopy recovery room.
2. There was no emergency lighting in the endoscopy procedure room.
3. There were no emergency receptacles in eight patient rooms on the ground floor.
4. no circuit and panel number indicated on the receptacle covers in two OB department ' s operating rooms:

Based on observations during the survey walk, the facility failed to provide a proper type I Essential electrical system.

Building #5 survey walk, the inspectors observed the following issues:
1. The panel for Generator #1 indicates it is fed from the Critical Branch. NFPA 99 requires the generator battery charger, lights, and outlet to be powered by the Life Safety Branch. Generator accessory power source branch could not be identified for generator #3.
2. Cover Plates: In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates, permanent adhesive engraved laminated labels or labels covered with clear coating. The circuit and panel number was not indicated on the receptacle covers in the following locations: 1) ED, and 2) other miscellaneous areas. See following definition of critical areas. Critical care areas are defined as special care units, intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, operating rooms, post-anesthesia recovery rooms, emergency departments, and similar areas in which patients are intended to be subjected to invasive procedures and connected to line-operated, patient-care-related electrical appliances, re NFPA 99, 2002, 3.3.135.2.)
3. The fire alarm control panel must have a label indicating the panel and breaker supplying power and the breaker in the electrical panel must have a label adjacent to the breaker indicating " FIRE ALARM CIRCUIT CONTROL " and the breaker shall be colored red. The breaker for the main FACP was not colored red.
4. The EES panels must be labeled according to the branch they serve. This must be addressed in the following locations: 1) on the 3rd floor at the Acute Rehab, 2) the electrical room at the Cath Lab, 3) pharmacy electrical room, 4) kitchen electrical room.

Based on observations during the survey walk of Building #5, the facility failed to provide acceptable electrical wiring and equipment in accordance with NFPA 70, the National Electrical Code.
The inspectors observed the following:
1. Junction boxes did not have covers or were not closed in the plenum space above the following doors: 1) lobby doors for elevators 3 and 4 on the 3rd floor, 2) door SMK-2A-3
2. Junction boxes did not have covers in the following rooms: 1) Mechanical room in the Basement, 2) Lab breakroom,