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A. Portions of the building were observed to not be in compliance with 19.1.6.2. with respect to fire resistive construction type, as described below.

1. During an interview held in the Office of the Chief Financial Officer on the morning of June 5, 2007, the provider's Director of Support Services was not able to identify the intended UL Design for the original building's roof/ceiling assembly and floor/ceiling assemblies. Surveyor 14290 notes that the systems appear to include a plaster membrane on the underside of the open web steel joists, but that fire dampers could not be verified at all penetrations of this membrane by supply, return, or exhaust ductwork. Compliance with 19.1.6.2. could thus not be demonstrated.

2. Portions of the building were observed at which the plaster membrane had been removed from the underside of the open web steel joists, thus compromising the apparent original building construction type. Compliance with 19.1.6.2. could thus not be demonstrated. Surveyor 14290 notes that this condition appears to be prevalent throughout the building. Portions of the building where this condition was observed include:

a. Third Floor:
1) A Wing.
b. First Floor Corridor to Medical Arts Building.

3. One story portions of the building were observed to be of Type II (000) construction and to not be separated from the adjacent, higher construction type by minimum 2 hour fire rated construction as required by 19.1.1.4.1. or 19.1.6.2. Locations observed include:
a. First Floor:
UPDATE 8/19/10: at the cross corridor doors (ID7) located in the 2 hour wall, it was noted that the steel I beam above the ceiling was enclosed or protected. It was also noted that the doors located in this 2 hour rated separation did not contain fire rated hardware.

UPDATE 4/26/12: at the cross corridor doors (ID7) located in the 2 hour wall, it was noted that the steel I beam above the ceiling was NOT enclosed or protected. It was also noted that the doors located in this 2 hour rated separation have now been replaced.

b. Corrected 8/19/10

4 Duct penetrations were observed, through the plaster membrane on the underside of the open web steel joists, that are not equipped with fire dampers that are required by the UL Design for the roof/ceiling assembly or floor/ceiling assembly and for compliance with 19.1.6.2. Locations observed include:

a. Third Floor D Wing Mechanical Room, 4 ducts (1 at each air handling unit).

UPDATE 1/7/09, Relative to item 4 above: Although existing fire dampers were observed to exist in the branch supply ducts at the presumed perimeter wall(s) of the mechanical rooms to separate the supply ducts within mechanical space from the ducts beyond the mechanical space within the above ceiling cavity, it is still not clear that a complete separation of the mechanical room from the above ceiling cavity is provided. The above ceiling cavity is utilized as a return plenum and is also part of the ceiling/roof assembly or ceiling/floor assembly. The observed fire dampers do not appear to serve to provide the required protection of the ceiling/roof or ceiling/floor assemblies. Fire dampers appear to be required where the supply ducts penetrate the ceiling membrane. The ceiling membrane needs to form a complete barrier between the mechanical space and the above ceiling cavity. Voids were observed between the ducts observed with the dampers.

A. Based on random observation during the survey walk-through, document review, and staff interview, not all ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. Findings include:
A representative of the provider's Consulting Engineer stated that exhaust shafts exist between the pairs of Patient Sleeping Rooms (or at individual Patient Sleeping Rooms) and that such shafts communicate between the Third and Second Floors of the building; however, penetrations through these shaft walls do not appear to be equipped with fire dampers as required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1. Surveyor 14290 notes that:

1. Based on drawing review, there appear to be approximately 24 shafts of this type.

2. Duct penetrations lacking the required fire dampers appear to exist:

a. At Second Floor Patient Toilet Room exhaust grilles.

b. At Third Floor Patient Toilet Room exhaust grilles.

c. On the Third Floor where exhaust ducts exit the shaft enclosures to gather prior to passing through the roof/ceiling assembly.
Surveyor notes that, during an interview held in the Administrative Conference Room on the morning of August 18, 2008, hospital representatives presented a sample of a damper assembly, equipped with a fusible link, that had been removed from exhaust duct within the shaft wall at a Patient Sleeping Room Toilet. It is noted that the damper is not within the plane of the wall, is not sufficiently latching, and cannot be inspected or serviced.

B. Surveyor notes that the UL Designs for the presumed ceiling/floor assemblies utilized for most areas of the building appear to include fire dampers at supply, return, and exhaust diffusers; however these fire dampers do not appear to be in place. Also refer to K-012.

A. The generator did not have the required 96 hours of fuel storage, NFPA 110, 1996, 3-1.2.

B. UPDATE 1/7/09: Hospitals are required to maintain a Level 1 emergency generator system. NFPA 99, 1999, 3-4.1.1.4(a) specifies that Type I essential electrical system power sources shall be classified as Type 10 (10 second interuption of power supply), Class X (greater than 48 hour run time without refueling), Level 1 (failure may result in loss of life or serious injury) generator sets per NFPA 110. NFPA 110, 3-1.2 requires that Level 1 generator sets in seismic risk areas be operational for a minimum of 96 hours without refueling. The facility is considered to be located in a seismic risk area.

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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.

A) Based on random observation during the survey walk-through and staff interview, not all elevators within the facility conform with firefighters' service requirements of ANSI/ASME A17.3. All elevators within the building were observed to lack smoke detectors, located at each respective car landing, that comply with 19.5.3., 9.4.3.2., ANSI/ASME A17.3 1993 3.11.3. and ANSI/ASME A171. 1993 211.3b. During an interview held in the Elevator Lobby on the afternoon of September 13, 2006, the provider's Director of Support Services confirmed this observation.