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It was determined by observation during the course of the survey on March 24-31, 2010, that a two hour fire-rated separation between the Skilled Nursing facility and the remainder of the 2nd Floor/Center section of the hospital building was compromised or did not exist, in accordance with LSC section 19.1.2.

The fire rated separation wall between the TCU and the remainder of the 2nd Floor/Center section of the facility was not continuous from outside wall to outside wall and extend from the floor to the underside of the ceiling deck between:

1) Resident Room #C219 and the adjacent Shower Room #C134, and
2) Resident Room #C234 and the adjacent Mechanical Room.
3) The concrete block wall within the Mechanical Room #C2-135 was observed with several unsealed bored holes into the concrete blocks.

These two-hour rated wall deficiency items were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the course of the survey on March 24-31, 2010, that the facility failed to maintain the fire protection features to the building structure in accordance with Life Safety Code section 19.1.6. This was evidenced by the following:

1) A Mechanical area, divided into two compartments by a one hour rated smoke barrier wall, and accessible on one side by door #C2-117. The divided mechanical area was approximately 55 ft. x 125 ft. x 10 ft. on the east side and 55 ft. x 100 ft. x 10 ft. on the west side. These two mechanical areas were provided with an extensive network of raised wooden walkways/flooring system that was constructed of fire retardant treated dimensional lumber and plywood decking. The raised wooden walkways ranged from 2 ft. to 4 ft. wide. Combustible wood products are not permitted within a Type I structure.
2) Storage Room #C2-315 had a 4" diameter unsealed hole at an electrical conduit penetration in the 2-hour fire-rated wall above the suspended ceiling tile.

These building structure deficiency items were observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the course of the survey on March 24-31, 2010, that the facility failed to provide proper smoke resistive separation between the egress corridor and adjacent rooms in accordance with the Life Safety Code section 19.3.6.1. This was evidenced by the following:

The corridor wall to the Electrical Room #C2-139 had a 12" x 12" louvered vent with a fusible link installed through the wall above the corridor door, allowing air transfer between the room and corridor. This room was no longer considered to be smoke resistive from the egress corridor. Transfer grilles, regardless of whether they are protected by fusible link operated dampers, shall not be used in corridor walls or doors, in accordance with LSC section 19.3.6.4.

This smoke resistive corridor wall deficiency item was observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the course of the survey on March 24-31, 2010, that the integrity of the stair enclosure was not maintained in accordance with LSC section 7.2.2.5 and referenced section 7.1.3.2. This was evidenced by the following:

An electrical cable was observed to penetrate into the stair enclosure and exit within an approximate 40" distance in north stair #801. In accordance with section 7.1.3.2.(e), penetrations into the stair enclosure were not limited to items that serve only the stair enclosure.

This vertical opening deficiency item was observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the survey on March 24-31, 2010, that the facility failed to properly protect the hazardous areas with construction that was smoke-resisting in accordance with section 19.3.2.1 of the Life Safety Code. This was evidenced by the following hazardous areas that were sprinkler protected, but were not maintained to be smoke-resistive:

The File Storage Room, C2-346 was being used as a combustible storage location that was greater than 50 sq. ft. The 1?" thick corridor door was without a means of self-closing. Doors protecting hazardous areas must be equipped with a means of self-closing and remain closed at all times when not in use unless placed on a magnetic holding device.

The hazardous area deficiency item was observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the survey on March 24-31, 2010, that the facility failed to provide a complete coverage automatic fire sprinkler system, installed in accordance with NFPA Standard 13, Installation of Sprinkler Systems for all portions of the facility. This was evidenced by the following locations that were not protected by the fire sprinkler system:

1.) A Mechanical area, divided into two compartments by a one hour rated smoke barrier wall, and accessible on one side by door #C2-117. The divided mechanical area was approximately 55 ft. x 125 ft. x 10 ft. on the east side and 55 ft. x 100 ft. x 10 ft. on the west side. Each of the above mechanical areas were not protected by automatic fire sprinkler system coverage. This mechanical area also serves as an attic space for the Laboratory.
2.) A soiled linen chute located near/across from door #C2-101 was not properly internally protected by the automatic sprinkler system in accordance with NFPA 13, section 5-13.5. The chute was believed to extend to a height of four stories at this location. This chute was recognized to have been provided with only one sprinkler head, located at the top of the chute.

NFPA 13, Installation of Sprinkler Systems, Section 1-6.1 states: "A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas".

These sprinkler protection deficiency items were observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the course of the survey on March 24-31, 2010, that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

Air/water pressure gauges were not replaced, or recalibrated, every five (5) years in accordance with (1998) NFPA 25, section 2-3.2. The facility was observed with a water pressure gauges located within the stair tower #C2-809, to the north of the TCU wing, that were dated 2005.

The fire sprinkler system deficiency item was observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the survey on March 24-31, 2010, that the facility failed to provide exit corridors that were maintained clear and unobstructed in accordance with (2000) LSC section 19.2.1 and referenced 7.1.10. This was evidenced by the following:

1.) It was observed that two chairs and a table, approximately 2 ft. x 2 ft., with two potted floor plants were being stored within the corridor outside room #C2-321.
2.) A continuous glass wall and door assembly, identified as C2-706, was installed within the corridor that extended fully from floor to ceiling and from wall to wall near room #C2-332. A 36 inch door was installed adjacent to a 32" glass wall within the 5 ft. 9 inch wide corridor. The glass wall and door assembly and the stored items reduce the width of the exit corridor, which must be maintained clear and unobstructed.
3.) A wall mounted drinking fountain was installed within the exit corridor and extended out from the corridor wall approximately 18". This item reduced the width of the 65" wide exit corridor, which must be maintained clear and unobstructed. Projections greater than 3.5" at a height below 38" are not permitted in accordance with LSC section 7.3.2.
4.) It was observed at 3:30 p.m., on 3/30/2010, and again at 8:30 a.m., on 3/31/2010, that a patient bed was being stored within the corridor outside of the Dayroom #C2-132.
5.) It was observed at 8:45 a.m. and again at 10:00 a.m., on 3/31/2010, that a patient lift was being stored within the corridor/Elevator Lobby for elevators #10, #11 and #12.
6.) It was observed at 9:00 a.m., and again at 9:45 a.m., on 3/31/2010, that the following items were being stored within the 9 ft. wide by 114 ft. long "transport corridor" located between Buildings "B" and "C":

a) Eight (8) wheelchairs, each with an "E" series oxygen cylinder,
b) Two (2) transport beds,
c) 12 "E" series oxygen cylinders in three racks,
d) Three (3) patient lifts,
e) An 18 inch x 3 ft. x 6 ft. storage locker,
f) Four (4) storage racks consisting of PCA machines, K-Pad machines, Pulse Ox machines, Syringe and Tube Feeding machines, and
g) Five (5) transport chairs each with an "E" series oxygen cylinder.

These corridor obstruction deficiency items were observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the survey on March 24-31, 2010, that the facility failed to properly provide appropriate storage for the containers handling soiled linen in accordance with section 19.7.5.5 of the Life Safety Code. This was evidenced by the following:

A mobile soiled linen collection receptacle with capacities greater than 32 gallons was staged unattended within the corridor/Elevator Lobby for elevators #10, #11 and #12, and was not located in a room protected as a hazardous area when not attended.

This soiled linen deficiency item was observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the course of the survey on March 24-31, 2010, that a two hour fire-rated separation between the Skilled Nursing facility and the remainder of the 2nd Floor/Center section of the hospital building was compromised or did not exist, in accordance with LSC section 19.1.2.

The fire rated separation wall between the TCU and the remainder of the 2nd Floor/Center section of the facility was not continuous from outside wall to outside wall and extend from the floor to the underside of the ceiling deck between:

1) Resident Room #C219 and the adjacent Shower Room #C134, and
2) Resident Room #C234 and the adjacent Mechanical Room.
3) The concrete block wall within the Mechanical Room #C2-135 was observed with several unsealed bored holes into the concrete blocks.

These two-hour rated wall deficiency items were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the course of the survey on March 24-31, 2010, that the facility failed to maintain the fire protection features to the building structure in accordance with Life Safety Code section 19.1.6. This was evidenced by the following:

1) A Mechanical area, divided into two compartments by a one hour rated smoke barrier wall, and accessible on one side by door #C2-117. The divided mechanical area was approximately 55 ft. x 125 ft. x 10 ft. on the east side and 55 ft. x 100 ft. x 10 ft. on the west side. These two mechanical areas were provided with an extensive network of raised wooden walkways/flooring system that was constructed of fire retardant treated dimensional lumber and plywood decking. The raised wooden walkways ranged from 2 ft. to 4 ft. wide. Combustible wood products are not permitted within a Type I structure.
2) Storage Room #C2-315 had a 4" diameter unsealed hole at an electrical conduit penetration in the 2-hour fire-rated wall above the suspended ceiling tile.

These building structure deficiency items were observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the course of the survey on March 24-31, 2010, that the facility failed to provide proper smoke resistive separation between the egress corridor and adjacent rooms in accordance with the Life Safety Code section 19.3.6.1. This was evidenced by the following:

The corridor wall to the Electrical Room #C2-139 had a 12" x 12" louvered vent with a fusible link installed through the wall above the corridor door, allowing air transfer between the room and corridor. This room was no longer considered to be smoke resistive from the egress corridor. Transfer grilles, regardless of whether they are protected by fusible link operated dampers, shall not be used in corridor walls or doors, in accordance with LSC section 19.3.6.4.

This smoke resistive corridor wall deficiency item was observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the course of the survey on March 24-31, 2010, that the integrity of the stair enclosure was not maintained in accordance with LSC section 7.2.2.5 and referenced section 7.1.3.2. This was evidenced by the following:

An electrical cable was observed to penetrate into the stair enclosure and exit within an approximate 40" distance in north stair #801. In accordance with section 7.1.3.2.(e), penetrations into the stair enclosure were not limited to items that serve only the stair enclosure.

This vertical opening deficiency item was observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the survey on March 24-31, 2010, that the facility failed to properly protect the hazardous areas with construction that was smoke-resisting in accordance with section 19.3.2.1 of the Life Safety Code. This was evidenced by the following hazardous areas that were sprinkler protected, but were not maintained to be smoke-resistive:

The File Storage Room, C2-346 was being used as a combustible storage location that was greater than 50 sq. ft. The 1?" thick corridor door was without a means of self-closing. Doors protecting hazardous areas must be equipped with a means of self-closing and remain closed at all times when not in use unless placed on a magnetic holding device.

The hazardous area deficiency item was observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the survey on March 24-31, 2010, that the facility failed to provide a complete coverage automatic fire sprinkler system, installed in accordance with NFPA Standard 13, Installation of Sprinkler Systems for all portions of the facility. This was evidenced by the following locations that were not protected by the fire sprinkler system:

1.) A Mechanical area, divided into two compartments by a one hour rated smoke barrier wall, and accessible on one side by door #C2-117. The divided mechanical area was approximately 55 ft. x 125 ft. x 10 ft. on the east side and 55 ft. x 100 ft. x 10 ft. on the west side. Each of the above mechanical areas were not protected by automatic fire sprinkler system coverage. This mechanical area also serves as an attic space for the Laboratory.
2.) A soiled linen chute located near/across from door #C2-101 was not properly internally protected by the automatic sprinkler system in accordance with NFPA 13, section 5-13.5. The chute was believed to extend to a height of four stories at this location. This chute was recognized to have been provided with only one sprinkler head, located at the top of the chute.

NFPA 13, Installation of Sprinkler Systems, Section 1-6.1 states: "A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas".

These sprinkler protection deficiency items were observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the course of the survey on March 24-31, 2010, that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

Air/water pressure gauges were not replaced, or recalibrated, every five (5) years in accordance with (1998) NFPA 25, section 2-3.2. The facility was observed with a water pressure gauges located within the stair tower #C2-809, to the north of the TCU wing, that were dated 2005.

The fire sprinkler system deficiency item was observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the survey on March 24-31, 2010, that the facility failed to provide exit corridors that were maintained clear and unobstructed in accordance with (2000) LSC section 19.2.1 and referenced 7.1.10. This was evidenced by the following:

1.) It was observed that two chairs and a table, approximately 2 ft. x 2 ft., with two potted floor plants were being stored within the corridor outside room #C2-321.
2.) A continuous glass wall and door assembly, identified as C2-706, was installed within the corridor that extended fully from floor to ceiling and from wall to wall near room #C2-332. A 36 inch door was installed adjacent to a 32" glass wall within the 5 ft. 9 inch wide corridor. The glass wall and door assembly and the stored items reduce the width of the exit corridor, which must be maintained clear and unobstructed.
3.) A wall mounted drinking fountain was installed within the exit corridor and extended out from the corridor wall approximately 18". This item reduced the width of the 65" wide exit corridor, which must be maintained clear and unobstructed. Projections greater than 3.5" at a height below 38" are not permitted in accordance with LSC section 7.3.2.
4.) It was observed at 3:30 p.m., on 3/30/2010, and again at 8:30 a.m., on 3/31/2010, that a patient bed was being stored within the corridor outside of the Dayroom #C2-132.
5.) It was observed at 8:45 a.m. and again at 10:00 a.m., on 3/31/2010, that a patient lift was being stored within the corridor/Elevator Lobby for elevators #10, #11 and #12.
6.) It was observed at 9:00 a.m., and again at 9:45 a.m., on 3/31/2010, that the following items were being stored within the 9 ft. wide by 114 ft. long "transport corridor" located between Buildings "B" and "C":

a) Eight (8) wheelchairs, each with an "E" series oxygen cylinder,
b) Two (2) transport beds,
c) 12 "E" series oxygen cylinders in three racks,
d) Three (3) patient lifts,
e) An 18 inch x 3 ft. x 6 ft. storage locker,
f) Four (4) storage racks consisting of PCA machines, K-Pad machines, Pulse Ox machines, Syringe and Tube Feeding machines, and
g) Five (5) transport chairs each with an "E" series oxygen cylinder.

These corridor obstruction deficiency items were observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.

It was determined by observation during the survey on March 24-31, 2010, that the facility failed to properly provide appropriate storage for the containers handling soiled linen in accordance with section 19.7.5.5 of the Life Safety Code. This was evidenced by the following:

A mobile soiled linen collection receptacle with capacities greater than 32 gallons was staged unattended within the corridor/Elevator Lobby for elevators #10, #11 and #12, and was not located in a room protected as a hazardous area when not attended.

This soiled linen deficiency item was observed within a business occupancy portion (C2) of the hospital as it was evaluated to healthcare requirements and were discussed with the Fire Prevention Safety Officer during a tour of the facility.