HospitalInspections.org

During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that the stairways and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour.
Based on observation at various times during the survey it was noted that the following vertical openings separations had penetrations that were not protected properly
a.) Room BE023 repair ceiling and access door had been left open
b.) Room B56
c.) Room B47-7.9 unprotected opening in shaft
d.) 4th floor Stair 11/12 at Fireman ' s phone jack
e.) 5th floor room 5C037
f.) 5th floor across from room 5D527
g.) 5th floor room 5D043
h.) 2nd floor stairwell 11 door not closing and latching properly
i.) 2nd floor room 2C008
j.) Room 2D224
k.) Room 2G021
l.) Room GK057
m.) 8th floor room 8D020
n.) 8th floor room 8C002
o.) 8th floor room 8A016
p.) 8th floor room 8A060
q.) 8th floor room 8B0011
r.) 8th floor room 8B009
s.) 8th floor room 8E819-1
t.) 6th floor room electrical room C hall
u.) 7th floor broken glass stairway 16
v.) 10th floor Stair 12
w.) 11th floor stairwell 1
An interview with staff members M1, M2, M3, and M4 conducted at various times revealed that the facility was unaware that these vertical opening separations had unprotected penetrations.

During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that Smoke barriers are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.


1.) During the standard survey at 10:05 it was observed that the smoke doors at the elevator lobby on the 16th floor failed to latch properly. Due to the doors protecting the elevator lobby they are required to positively latch.

An interview with staff member M3 conducted at 10:08 revealed that the facility was unaware that these doors were not latching properly.


2.) During the standard survey at various times it was observed that smoke doors in the following locations were not provided with an Astragal and the gap in the door exceeded the allowable limit.
a.) Doors at 15A
b.) Doors at room 11A19
c.) Doors B227062 9th floor Elevator lobby
d.) Doors at the Burn unit corridor
An interview with staff members M1, M2, M3, and M4 conducted at various times revealed that the facility was unaware that these doors were required to be provided with an Astragal.
3.) Based on observation at various times during the survey it was noted that the following smoke walls had penetrations that were not protected properly.
a.) Above the ceiling at smoke doors 15A034
b.) Above the ceiling near room BK002
c.) Above the ceiling over smoke door number 0225513 near room BH012 had penetrations.
d.) The smoke barrier at the Engineering storage room around pipes and conduits.
e.) Smoke barrier at the 12th floor Corridor 12A smoke doors area above the ceiling.
f.) At 5C elevator lobby
g.) At room 5D629 above ceiling around sprinkler pipe
h.) At room 5D527 above ceiling around sprinkler pipe
i.) At room 5G002
j.) At room 2C008 above ceiling
k.) At room 2E0222 ceiling penetrations
l.) Smoke barriers on Ground floor
m.) 8th floor A hall elevator lobby
n.) 8th floor room 8A60 above ceiling
o.) 6th floor room 6B053
p.) 9th floor room 9B012
q.) 9th floor room 9B010
r.) 12th floor room 12E006
s.) 10th floor room 10B014
t.) 8th floor 8A above ceiling at smoke doors
u.) 8th floor room 8A015
v.) 8th floor room 8A016
w.) 8th floor room 8A016
x.) 8th floor room 8A018
y.) 8th floor room 8A082
z.) 8th floor room 8B009
aa.) 14th floor above smoke doors corridor 14A
bb.) 14th floor women ' s corridor at smoke doors above ceiling
cc.) 14th floor at room 148042
dd.) At room BJ006 above ceiling
ee.) At room BK002 above ceiling
ff.) At door GDY-BF901 above ceiling
gg.) At doors 0225513 near room BH012 above ceiling
An interview with staff members M1, M2, M3, and M4 conducted at various times revealed that the facility was unaware that these smoke walls had unprotected penetrations.

3.) During the standard survey at various times it was observed that the smoke barriers in some areas had been sealed with non- rated expandable foam insulation.
Interviews with staff members M1, M2, M3, and M4 conducted at various times during the survey revealed that the facility was unaware that this product had been used and the process of cutting it out and replacing it with approved sealant was started at the time of this survey.

During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that Hazardous areas were separated from other spaces by smoke resisting partitions and self-closing doors.
1.) Based on observation at various times during the survey it was noted that the following separation walls had penetrations that were not protected properly or doors not provided with self closing devices.
a.) Room BC053 door is not labeled as being rated and is not provided with a self closer.
b.) Room BC053 penetrations in walls
c.) CED storage Room
d.) Room BH025 elevator equipment room
e.) Room BC054
f.) Room BE021 no self closer
g.) 72K room Pharmacy Storage Overflow
h.) Room BB-014
i.) Room 5B056
j.) Room GK057
k.) Room 1D018
l.) Room 1B029 needs to be positive latching
m.) 8th floor room 8A015
n.) 8th floor room 8A018
o.) 8th floor room 8A082
p.) 9th floor A hall janitor ' s closet
q.) 12th floor 12E electrical room
r.) 12th floor room 12D016
s.) 15th floor room C1501
An interview with staff members M1, M2, M3, and M4 conducted at various times revealed that the facility was unaware that these smoke walls to separate hazardous areas had unprotected penetrations.


2.) Based on observation at 1330 hours it was noted that room BE057 had been converted to a storage area for stocked clean linen carts. The sheetrock walls have been damaged at several points voiding the rating it might have had. Also if the original classification for the room was light hazard for sprinkler system coverage, the room classification is now higher and the sprinkler classification needs to be upgraded. The doors for this room have been damaged and are not closing and latching properly.
An interview with staff member M3 revealed that the facility was not aware that the room had been damaged.
3.) Based on observation at 1345 hours it was noted that room BE065 had been converted to a storage area for linen carts and the room is not sprinkler protected nor is it separated with the required hourly rating.
An interview with staff member M3 revealed that the facility was not aware that the room was not properly constructed and sprinkler protected.

During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that the required Exit access is arranged so that exits were readily accessible at all times.
1.) Based on observation at 10:53 it was noted that a hasp lock was installed on the door for room 5B47.
An interview with staff member M3 revealed that the facility was unaware that this type lock could not be used for this door and the lock was removed.
2.) Based on observation at 10:00 it was noted that the exterior gate from the exterior stair is not provided with a release of the locking device except for release upon activation of the fire alarm system.
An interview with staff member M2 revealed that the facility was unaware that a second means of releasing this lock was required.
3.) Based on observation at 1400 hours it was noted that the second means of egress from the Engineering Storage Room had been closed over.
An interview with staff member M2 revealed that the facility was unaware that this had been a required exit.

1.) During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that the required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically.
During a review of the documentation of sprinkler inspections at 10:30 it was noted that the last sprinkler inspection date was during the year 2009.
During an interview with staff member SVPOF at 10:45 it was acknowledged that the sprinkler inspection had been overlooked last year, but that an inspection of the system was underway by a State Licensed Sprinkler Contractor but that due to the size of the facility the inspection of the system would not be complete before the end of this survey.
2.) During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that the required automatic sprinkler covered all areas of the facility.
Based on observation at 1410 hours it was noted that the sprinkler riser room and room BC055 was not protected by the sprinkler system. This room also has a wooden roof structure which is not allowed by the construction type of this facility.
An interview with staff member M3 it was determined that the facility was unaware that these areas were not covered by the sprinkler system.

During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that Portable space heating devices used in non-sleeping staff and employee areas had heating elements that did not exceed 212 degrees F (100 degrees C) and that the units were listed for use in other than residential facilities.
Based on observation, at various times throughout the survey, it was noted that portable space heating units were located throughout the facility in non-sleeping and staff areas. It could not be determined what the heating element rating of these units was and they did not state that they were approved for use in other than residential facilities.
During interviews with staff members M1, M2, M3, and M4 the portable space heaters were discussed and the staff could not provide the information about the units that were in use meeting the requirements of this section.
The staff did remove the units in question during the survey.

1. During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that the Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code.
During the standard survey at varying times it was observed that the following electrical code violations were present.
a.) Open electrical boxes behind exhaust fan18th floor
b.) Open electrical boxes in elevator equipment room 18th floor
c.) Open junction box room GB050
d.) Void in electrical panel room 5E014
e.) Void in electrical panel room 2G021
f.) Open junction box room GG016 closet
g.) Ensure that all electrical panels throughout the facility have a three foot work space maintained around them
h.) Open junction box room B44-7.9
i.) Open junction box room BA046
j.) Open junction box room B56
k.) A Protective cover missing on electrical outlet room BA-002
l.) Void in electrical panel 8DNBA
m.) Void in electrical panel room 6D024
n.)Void in electrical panel room 8D018
o.) Void in electrical panel room 8C003
p.) Void in electrical panel room 6D024
Interviews were conducted with staff members M1, M2, M3, and M4 throughout the time of the survey in which they advised that they were unaware of the above electrical code violations. However most of these items were corrected during the time of the survey.

2. During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that the Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code.
Based on observation at various times during the survey at varying times it was observed that re-locatable power taps (multi plug power strips) were in use throughout the facility without being properly mounted or secured to prevent physical damage as required by the electrical code.
Interviews with staff members M1, M2, M3, and M4 were conducted throughout survey about this item and they advised that the maintenance staff were unaware that these power strips were in use without being properly mounted and that the strips installed by the maintenance staff were installed properly.

During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that the stairways and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour.
Based on observation at various times during the survey it was noted that the following vertical openings separations had penetrations that were not protected properly
a.) Room BE023 repair ceiling and access door had been left open
b.) Room B56
c.) Room B47-7.9 unprotected opening in shaft
d.) 4th floor Stair 11/12 at Fireman ' s phone jack
e.) 5th floor room 5C037
f.) 5th floor across from room 5D527
g.) 5th floor room 5D043
h.) 2nd floor stairwell 11 door not closing and latching properly
i.) 2nd floor room 2C008
j.) Room 2D224
k.) Room 2G021
l.) Room GK057
m.) 8th floor room 8D020
n.) 8th floor room 8C002
o.) 8th floor room 8A016
p.) 8th floor room 8A060
q.) 8th floor room 8B0011
r.) 8th floor room 8B009
s.) 8th floor room 8E819-1
t.) 6th floor room electrical room C hall
u.) 7th floor broken glass stairway 16
v.) 10th floor Stair 12
w.) 11th floor stairwell 1
An interview with staff members M1, M2, M3, and M4 conducted at various times revealed that the facility was unaware that these vertical opening separations had unprotected penetrations.

During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that Smoke barriers are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.


1.) During the standard survey at 10:05 it was observed that the smoke doors at the elevator lobby on the 16th floor failed to latch properly. Due to the doors protecting the elevator lobby they are required to positively latch.

An interview with staff member M3 conducted at 10:08 revealed that the facility was unaware that these doors were not latching properly.


2.) During the standard survey at various times it was observed that smoke doors in the following locations were not provided with an Astragal and the gap in the door exceeded the allowable limit.
a.) Doors at 15A
b.) Doors at room 11A19
c.) Doors B227062 9th floor Elevator lobby
d.) Doors at the Burn unit corridor
An interview with staff members M1, M2, M3, and M4 conducted at various times revealed that the facility was unaware that these doors were required to be provided with an Astragal.
3.) Based on observation at various times during the survey it was noted that the following smoke walls had penetrations that were not protected properly.
a.) Above the ceiling at smoke doors 15A034
b.) Above the ceiling near room BK002
c.) Above the ceiling over smoke door number 0225513 near room BH012 had penetrations.
d.) The smoke barrier at the Engineering storage room around pipes and conduits.
e.) Smoke barrier at the 12th floor Corridor 12A smoke doors area above the ceiling.
f.) At 5C elevator lobby
g.) At room 5D629 above ceiling around sprinkler pipe
h.) At room 5D527 above ceiling around sprinkler pipe
i.) At room 5G002
j.) At room 2C008 above ceiling
k.) At room 2E0222 ceiling penetrations
l.) Smoke barriers on Ground floor
m.) 8th floor A hall elevator lobby
n.) 8th floor room 8A60 above ceiling
o.) 6th floor room 6B053
p.) 9th floor room 9B012
q.) 9th floor room 9B010
r.) 12th floor room 12E006
s.) 10th floor room 10B014
t.) 8th floor 8A above ceiling at smoke doors
u.) 8th floor room 8A015
v.) 8th floor room 8A016
w.) 8th floor room 8A016
x.) 8th floor room 8A018
y.) 8th floor room 8A082
z.) 8th floor room 8B009
aa.) 14th floor above smoke doors corridor 14A
bb.) 14th floor women ' s corridor at smoke doors above ceiling
cc.) 14th floor at room 148042
dd.) At room BJ006 above ceiling
ee.) At room BK002 above ceiling
ff.) At door GDY-BF901 above ceiling
gg.) At doors 0225513 near room BH012 above ceiling
An interview with staff members M1, M2, M3, and M4 conducted at various times revealed that the facility was unaware that these smoke walls had unprotected penetrations.

3.) During the standard survey at various times it was observed that the smoke barriers in some areas had been sealed with non- rated expandable foam insulation.
Interviews with staff members M1, M2, M3, and M4 conducted at various times during the survey revealed that the facility was unaware that this product had been used and the process of cutting it out and replacing it with approved sealant was started at the time of this survey.

During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that Hazardous areas were separated from other spaces by smoke resisting partitions and self-closing doors.
1.) Based on observation at various times during the survey it was noted that the following separation walls had penetrations that were not protected properly or doors not provided with self closing devices.
a.) Room BC053 door is not labeled as being rated and is not provided with a self closer.
b.) Room BC053 penetrations in walls
c.) CED storage Room
d.) Room BH025 elevator equipment room
e.) Room BC054
f.) Room BE021 no self closer
g.) 72K room Pharmacy Storage Overflow
h.) Room BB-014
i.) Room 5B056
j.) Room GK057
k.) Room 1D018
l.) Room 1B029 needs to be positive latching
m.) 8th floor room 8A015
n.) 8th floor room 8A018
o.) 8th floor room 8A082
p.) 9th floor A hall janitor ' s closet
q.) 12th floor 12E electrical room
r.) 12th floor room 12D016
s.) 15th floor room C1501
An interview with staff members M1, M2, M3, and M4 conducted at various times revealed that the facility was unaware that these smoke walls to separate hazardous areas had unprotected penetrations.


2.) Based on observation at 1330 hours it was noted that room BE057 had been converted to a storage area for stocked clean linen carts. The sheetrock walls have been damaged at several points voiding the rating it might have had. Also if the original classification for the room was light hazard for sprinkler system coverage, the room classification is now higher and the sprinkler classification needs to be upgraded. The doors for this room have been damaged and are not closing and latching properly.
An interview with staff member M3 revealed that the facility was not aware that the room had been damaged.
3.) Based on observation at 1345 hours it was noted that room BE065 had been converted to a storage area for linen carts and the room is not sprinkler protected nor is it separated with the required hourly rating.
An interview with staff member M3 revealed that the facility was not aware that the room was not properly constructed and sprinkler protected.

During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that the required Exit access is arranged so that exits were readily accessible at all times.
1.) Based on observation at 10:53 it was noted that a hasp lock was installed on the door for room 5B47.
An interview with staff member M3 revealed that the facility was unaware that this type lock could not be used for this door and the lock was removed.
2.) Based on observation at 10:00 it was noted that the exterior gate from the exterior stair is not provided with a release of the locking device except for release upon activation of the fire alarm system.
An interview with staff member M2 revealed that the facility was unaware that a second means of releasing this lock was required.
3.) Based on observation at 1400 hours it was noted that the second means of egress from the Engineering Storage Room had been closed over.
An interview with staff member M2 revealed that the facility was unaware that this had been a required exit.

1.) During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that the required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically.
During a review of the documentation of sprinkler inspections at 10:30 it was noted that the last sprinkler inspection date was during the year 2009.
During an interview with staff member SVPOF at 10:45 it was acknowledged that the sprinkler inspection had been overlooked last year, but that an inspection of the system was underway by a State Licensed Sprinkler Contractor but that due to the size of the facility the inspection of the system would not be complete before the end of this survey.
2.) During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that the required automatic sprinkler covered all areas of the facility.
Based on observation at 1410 hours it was noted that the sprinkler riser room and room BC055 was not protected by the sprinkler system. This room also has a wooden roof structure which is not allowed by the construction type of this facility.
An interview with staff member M3 it was determined that the facility was unaware that these areas were not covered by the sprinkler system.

During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that Portable space heating devices used in non-sleeping staff and employee areas had heating elements that did not exceed 212 degrees F (100 degrees C) and that the units were listed for use in other than residential facilities.
Based on observation, at various times throughout the survey, it was noted that portable space heating units were located throughout the facility in non-sleeping and staff areas. It could not be determined what the heating element rating of these units was and they did not state that they were approved for use in other than residential facilities.
During interviews with staff members M1, M2, M3, and M4 the portable space heaters were discussed and the staff could not provide the information about the units that were in use meeting the requirements of this section.
The staff did remove the units in question during the survey.

1. During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that the Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code.
During the standard survey at varying times it was observed that the following electrical code violations were present.
a.) Open electrical boxes behind exhaust fan18th floor
b.) Open electrical boxes in elevator equipment room 18th floor
c.) Open junction box room GB050
d.) Void in electrical panel room 5E014
e.) Void in electrical panel room 2G021
f.) Open junction box room GG016 closet
g.) Ensure that all electrical panels throughout the facility have a three foot work space maintained around them
h.) Open junction box room B44-7.9
i.) Open junction box room BA046
j.) Open junction box room B56
k.) A Protective cover missing on electrical outlet room BA-002
l.) Void in electrical panel 8DNBA
m.) Void in electrical panel room 6D024
n.)Void in electrical panel room 8D018
o.) Void in electrical panel room 8C003
p.) Void in electrical panel room 6D024
Interviews were conducted with staff members M1, M2, M3, and M4 throughout the time of the survey in which they advised that they were unaware of the above electrical code violations. However most of these items were corrected during the time of the survey.

2. During the tour of the facility conducted by the SFM TEAM accompanied by Staff Members M1, M2, M3, and M4 it was noted that the facility failed to ensure that the Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code.
Based on observation at various times during the survey at varying times it was observed that re-locatable power taps (multi plug power strips) were in use throughout the facility without being properly mounted or secured to prevent physical damage as required by the electrical code.
Interviews with staff members M1, M2, M3, and M4 were conducted throughout survey about this item and they advised that the maintenance staff were unaware that these power strips were in use without being properly mounted and that the strips installed by the maintenance staff were installed properly.