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Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. This deficiency could affect any patients, staff, or visitors in the fire compartment housing the First Floor Imaging Department, because the condition lessens the construction type of the building.

Findings include:

A. At 1:43 PM on March 19, 2013, the construction type of the First Floor (apparent) building addition which houses X-Ray Rooms 1 and 2 was observed to be different than the rest of the building because the roof/ceiling assembly is constructed with open web steel joists and a drywall ceiling membrane in which unsealed penetrations were observed.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of separation could result in delayed response to fire/smoke conditions which compromise the facility's use of the exit access corridors.

The finding is:

A. Morning of 03/19/13 5th floor, The corridor wall located at the south end of the east/west corridor outside of Ambulatory Care does not provide a continuous separation between a use area and an exit access corridor. The wall contains flexible duct penetrations (located above the entry door to Ambulatory Care) which do not provide protection for the transfer of smoke to comply with 19.3.6.4 and NFPA 90 A 1999.

B. Patient care areas were observed open to an exit access corridor. The surveyor questioned if there were any suites within the facility to comply with 19.2.5 and was informed that there were none. The following areas comprise the locations which do not comply with 19.2.5.1:

1. Morning of 03/19/13 4th floor, Recovery

2. Morning of 03/19/13 4th floor, Pre-Op

3. Afternoon of 03/19/13 1st floor, Emergency Department

4. Afternoon of 03/18/13 5th floor, Ambulatory Care - West end of the floor.

C. Afternoon of 03/19/13, 4th floor, the corridor wall located above the north end sliding entry door to Same Day Surgery contains a large hole above the duct penetration which does not maintain a complete barrier to comply with 19.3.6.2.1.

D. Morning of 03/20/13, 2nd floor of South building contains a waiting area with an elevated ceiling. The unsupervised waiting area is open to the means of egress and lacks smoke detection to comply with 39.3.4 and 9.6.2.9 for signal initiation in common areas.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients within the smoke compartment, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. On the morning of 3/19/13, the 4th floor corridor door to Recovery was observed with a roller latch. This hardware installation does not comply with 19.3.6.3.2.

B. On the morning of 3/19/13, the 4th floor corridor sliding doors to Pre-Op (Same Day Surgery) were observed to have the following door hardware:

1. A thumb-turn lock-set which does not comply with 19.2.2.2.9 and 7.2.1.14 (1) for a readily operable door from both sides (the doors are not capable of latching from the corridor side).

2. A releasing device on both sides of the door having an obvious method of operation and readily operable under all lighting conditions which includes no light to comply with 7.2.1.5.4.

C. On the morning of 03/19/13 the 4th floor corridor doors for Operating rooms # 1 - # 4 were observed not to comply with 19.3.6.3.2 for latching hardware.

D. On the morning of 3/19/13, the 4th floor pair of cross corridor doors to 4 A Wing contain a delayed egress mechanism. The facility is not fully sprinkler protected therefore this hardware installation does not comply with 7.2.1.6.

Based on random observation during the survey walk-through, not all floor/ceiling assemblies are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any staff or visitors in the fire compartments housing the deficiencies by permitting smoke or fire to pass between building stories.

Findings include:

A. Pipe penetrations through floor/ceiling assemblies were observed to not be sealed against the passage of fire as required by 8.2.3.2.4.2. Locations observed include:
1. 3:01 PM March 18, 2013: Third Floor South Center IT Room, pipe sleeves at ceiling and floor.

2. 9:15 AM March 19, 2013: Second Floor South Center IT Room, pipe sleeves at ceiling.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. These deficiencies could affect any patients, staff, or visitors in the smoke compartments housing the deficiencies by permitting smoke or fire to pass from the hazardous areas to the rest of the compartment.

Findings include:

A. At 3:11 PM on March 18, 2013, unsealed pipe and other penetrations were observed in the south wall of the Third Floor Center East File Room as prohibited by 39.3.2.1. and 8.2.3.2.4.2.

B. At 10:38 AM on March 19, 2013, the door to the Basement Laboratory Storage Room was observed to not carry a minimum 3/4 hour fire rating as required by 39.3.2.1. and 8.2.3.2.3.1(2).

C. At 2:12 PM on March 18, 2013, the door to the Fifth Floor South Center Soiled Utility Room was observed to be damaged, thus compromising the minimum 3/4 hour fire rating required for the door by 19.3.2.1. and 8.2.3.2.3.1(2).


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D. Afternoon of 03/18/13 5th floor, soiled linen room is not provided with a self closing door to comply with 8.2.3.2.3.1 (2).

E. Afternoon of 03/18/13 5th floor mechanical room adjacent to the Ambulatory Care clinic contains a hole in the east wall which is not sealed to prevent the passage of smoke and fire.

F. Afternoon of 03/18/13 5th floor, Doctor's Office (indicated as a Equipment room on the Life Safety floor plans) contains numerous combustibles. Six shelves were observed which are 4.5 feet long by 2 feet deep. Each shelf contained a minimum of four stacks of papers that are each over 12 inches in height. In addition there are rows of paper stacks and folders which are two feet deep and eight feet in length. This AHJ deems this office as a hazardous area which does not comply with all requirements of 19.3.2.1 for a minimum 1-hour enclosure with a fire rated self closing door.

G. Afternoon of 03/19/13 4th floor, Operating room #4 was observed to contain storage of numerous combustible materials such as pillows, mattress covers, mattress pads and boxed table covers. This room is deemed a hazardous area by this AHJ and does not comply with 19.3.2.1 due to the following:

1. The corridor door is not fire resistant to comply with 8.2.3.2.4.2

2. The corridor door is not self closing to comply with 8.2.3.2.3.1 (2)

3. The room's walls are not indicated on the life safety plans to comply with 8.2.2.2.

H. Afternoon of 03/19/13 1st floor, Emergency Department Bays # 4 - # 6 was observed to contain storage of numerous combustible materials such as pillows, boxed and plastic wrapped medical supplies, gurneys with mattress pads lined up in bays (two in one treatment bay). This area is greater than 100 square feet, not separated from the patient treatment areas and is deemed a hazard by this AHJ. This area does not comply with 19.3.2.1.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any building occupants using the exit stairs because the stair enclosure could be compromised by smoke or fire, or by allowing a condition at which they could fall through the guardrails.

Findings include:

A. At 10:40 AM on March 19, 2013, rooms which are not normally occupied were observed to communicate directly with the Basement level enclosure for the Center East Exit Stair, as prohibited by 7.1.3.2.1(d). Rooms observed to open directly into the Exit Stair include:
1. The Boiler Room.
2. An Electrical Room.
B. At 9:20 AM on March 19, 2013, a series of unprotected windows were observed in the exterior walls of fire rated exit stair enclosures which are adjacent to windows in an exterior wall of the building which is at an angle to the exit stair enclosure wall of less than 180 degrees, as prohibited by 7.2.2.5.2. Locations observed include:
1. Center East Exit Stair: South wall of Fourth Floor.
2. Southwest Exit Stair (all north wall):
a. Fourth Floor.

b. Third Floor.

c. Second Floor.
d. First Floor.

C. At 2:57 PM on March 18, 2013, the distance between guardrails in exit stair enclosures was observed to be in excess of 4" as prohibited by 7.2.2.4.6(3). Exit stair enclosures at which this condition was observed include:

1. Southeast Exit Stair: All levels below the Fifth Floor.
2. Southwest Exit Stair: All levels.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors attempting to use the egress paths because the paths could become restricted.

Findings include:

A. At 9:08 AM on March 19, 2013, the following conditions were observed at the Fifth Floor Center "angled" wall adjacent to the Center Elevator and the Center West Exit Stair:

1. The clear width of the Corridor on both sides of the angled wall was observed to be reduced, as compared to corridor widths at either end of the wall. The angled wall is thus not arranged to avoid an obstruction to the convenient removal of building occupants as required by 19.2.3.3.

2. The door in the angled wall, when in the open (90 degree) position was observed to reduce the Corridor to less than half its required width as prohibited by 7.2.1.4.4.

B. At 10:30 AM on March 20, 2013, the following conditions were observed at the Corridor leading to the Fourth Floor south center portion of the building to the Southeast Exit Stair:
1. The two doors in the fire barrier were observed to not swing in the primary direction of egress as required by 7.2.1.4.2.
2. Because no exit sign was observed above the east face of the eastern-most door cited above, the Corridor between the doors in the east fire barrier and the Southeast Exit Stair constitutes a dead end corridor of excessive length as prohibited by 19.2.5.10.

C. At 10:18 AM on March 20, 2013, the Second Floor Corridor between the doors in the east fire barrier and the Southeast Exit Stair was observed to constitute a dead end corridor of excessive length, as prohibited by 19.2.5.10., because no exit sign was observed above the east face of the eastern-most door in the fire barrier.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the fire compartments on either side of the deficient barriers by permitting smoke or fire to pass between the fire compartments.

Findings include:

A. Doors in designated fire barriers were observed to not be self-closing as required by 8.2.3.2.3.1(1). Locations observed include:
1. 11:15 AM March 19, 2013: Door in fire barrier in middle of Basement Center Tunnel (accessible from Mechanical Room B).

2. East leaf of the First Floor Center pair of fire doors immediately south of Main Conference Room.



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F. On the afternoon of 03/19/13 the 4th floor fire rated cross corridor barrier doors located between 4B and 4A (near the Stair that is not an exit) contain a continuous vertical gap at the meeting stiles which does not comply with NFPA 80 for Standard for Fire Doors and Fire Windows.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect any staff in the Basement Laboratory because the exit access doors could be difficult to locate in emergency conditions.

Findings include:

A. At 10:53 AM on March 19, 2013, the egress paths within the Basement Laboratory were observed to not be identified by exit signs as required by 7.10.1.1. Egress paths observed to not be provided with exit signs include:

1. North door to Corridor.

2. South door to Corridor.

Based on random observation during the survey walk-through, document review, and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect any patients, staff, or visitors in the building because key life safety components could become compromised if not protected.

Findings include:

A. During an interview held in his Office on the afternoon of March 18, 2013, the provider's Hospital's Director of Plant Operations was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 19.7.1.1. Further, during the survey walk-through, it was determined that existing records of such components were inaccurate. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include (but are not necessarily limited to):

1. Occupancy classifications.

2. Fire barriers and their fire resistance ratings, including occupancy separations, horizontal exits, building separations, and separations between disparate construction types.

3. Exit Passageways.

4. Shaft enclosures and their fire resistance ratings, including exit stairs, exit discharge enclosures, elevators, ventilation shafts, and linen and/or refuse chute shafts.

5. Exit access corridors and designated corridor walls.

6. The limits and areas (in square feet) of all suites.

Based on random observation during the survey walk through the surveyor found that not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

Findings include:

A. The electrical panel at the 24 hour security location has circuits marked as feeding fire alarm that are not marked in red and equipped with a locking device as required by NFPA-72, Section 1-5.2.5.2.

B The Fire Alarm Control Panels are not labeled with the electrical panel designation and circuit number as required by NFPA 72, Section 1-5.2.5.

C. The fire alarm audible device located in the southeast corridor of the fourth floor did not operate when the fire alarm system was activated. The fire alarm was not audible on the third floor in the southeast corridor, on the first floor in the Greenview Health Suite and in other areas of the building in accordance with the 1999 Edition of NFPA-72, Chapter 4.

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:


A. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7.

B. The fire pump was not equipped with a transfer switch at the fire pump location and was not served from the emergency generator to comply with NFPA-20, Section 6.2.

A. Fire damper installation are incomplete or do not exist:

1. On the afternoon of 3/19/13 while in the company of the maintenance technician the surveyor finds access to and verification of fire damper installation is not provided at the following locations.

a. Lower Level Mechanical Room A:
The duct penetration (return or exhaust) through the floor above the air handling unit was not provided with an access panel for service and inspection of the required protection for the penetration. It could not be determined through observation, staff interview or review of the damper inventory that a damper is installed at this penetration.

b. Lower Level Telephone Switch Room:
Supply ducts that penetrate through to the floor above do not have access panels for service or inspection of installed fire or fire/smoke dampers. It could not be determined through observation, staff interview or review of the damper inventory that a damper is installed at these penetrations.

2. On the afternoon of 3/19/13 while in the company of the Hospital's Director of Plant Operations the surveyor finds at the 5th Floor Staff Lounge:

a. The exhaust inlet through the face of the shaft wall is not provided with a fire damper.

b. Observed through the ceiling access door above the ice machine, the installation of a fire damper from a duct penetration from the enclosing shaft for a horizontal run of exhaust duct above the ceiling. The enclosing shaft wall is not complete. Protection is not provided for this duct penetration. This fire damper is not included in the facility's fire damper inventory. ( Comment: Upon review of the 2010 damper inventory it appears to be incomplete for all installed dampers within the facility. The 2010 inspection and servicing report includes only picture of internal duct installations of the individual protecting devises and does not address the barrier penetration and its completeness. Those devises identified as failing in some respect in the 2010 report did not have any indication of the corrective action taken.)

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire to comply with 19.2.3.3. This condition may affect patients staff and visitors on the floor of incident.

The finding is:

A. On the afternoon of 03/19/13 3rd floor exit access corridors were observed being utilized for storage of equipment. Nursing equipment, and computers were observed plugged into and charging from corridor outlets. No staff were observed using the equipment.

A. Emergency Department:

Based on direct observation, the afternoon od 3/19/13 while in the company of the Maintenance Technician, the surveyor finds the facility failed to provide:

1. Separation by an intervening wall the medical gas zone valves and the outlets/inlets they serve for treatment bays 1 thru 6. (NFPA 99, 1999, 4-3.1.2.3 (d)

2. Zone valves for the outlets /inlets in Triage. (NFPA 99, 1999, 4-3.1.2.3 (d)

Based on random observation during the survey walk-through not all medical gas systems comply with with NFPA 99, 1999, Chapter 4. Failure to install and maintained medical gas systems in accordance with referenced standard could result in failure of those systems, while in use or needed for critical patients.

The findings are:

A. On the afternoon of 03/19/13 The 4th floor Surgery area medical gas systems contained a master zone shut off valve located behind a lockable door and within an office. This location does not comply with NFPA 99 1999 chapter 4 for the required access to the shut off valve.

B. On the afternoon of 03/19/13 the 4th floor Operating rooms 1, 2, 3 and 4 each lacked a medical gas shut off valve. The surveyor was informed that the only shut off valve is the master located within the office. Therefore, under an emergency conditions an individual Operating room cannot be shut down without shutting down all Operating rooms. This application does not comply with NFPA 99 1999 chapter 4.

Based on random observation during the survey walk-through, not all smoke barriers are constructed or maintained as fire/smoke resistive assemblies to comply with 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended smoke barrier protection between smoke compartments.

The finding is:

A. On the afternoon of 03/18/13 the 5th floor designated fire/smoke barrier between Wing 5 B and 5 A contained duct penetrations which were not protected against the spread of smoke and fire from one compartment to the adjacent compartment.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches as required by NFPA-70, Section 517-31 thru 35. The system one line diagram was not up to date and it did not show all emergency panels or what branch each transfer switch served, and most panels were not labeled with the branch of emergency power they served. Examples include:

1. Panel E5PH is serving a mixture of all three branches, life safety, critical and equipment.

2. Panel ETS01-5 serves a mixture of life safety and critical, including room receptacles (critical) Section 517-33, and elevator cab lighting that shall be served from life safety in accordance with section 517-32.

3. Panels CP2 and CP3 are new critical panels in the remodeled northeast wings on the second and third floors, and they are serving med gas alarms and emergency lighting which shall be served by the life safety panel to comply with Section 517-32.

4. Panel E2PA did not have enough detail in the circuit description to determine if it was life safety or critical.

5 The panel at the 24 hour security desk was serving life safety (fire alarm), and critical (receptacles), and had no panel identification.

7. Panel EBPA serves a mixture of life safety and equipment.

7. Two panels in the tunnel off of mechanical room B, EBPN and EBPO were labeled as critical panels , but served mostly equipment loads.

Based on random observation during the survey walk-through the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

A. Normal power receptacles were not provided in operating rooms on the fourth floor as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

B. Bonding of the piping for the gas system could not be located by staff as required by NFPA-70, Section 250-104(b). This could cause a potential difference between gas piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

C. The water meter was not equipped with a bonding jumper to comply with NFPA-70, Section 250-50(a)(1).

D. Emergency receptacles in the operating rooms on the fourth floor, and other patient bed locations were not labeled with the source panel and the circuit number in accordance with NFPA-70, Section 517-19(a). This could cause confusion during a power outage trying to locate an emergency receptacle for critical care equipment.

E. Patient bed location on the third floor in wing A were not equipped with emergency receptacles as required by NFPA-70, Section 517-18. This could effect any patient in this wing in the event of a power outage.

F. Panels in several location, including panels 5JP, 5PG, E4PK, E2PA, and several other locations, were either missing schedules or the schedules needed to be updated to comply with NFPA-70, Section 110-22. Schedules were handwritten, breakers were on but marked as spares or not labeled at all, and some panels including the panel at the 24 hour security desk and the emergency panel in the mechanical room 4 were not identified.

Based on random observation during the survey walk-through the surveyor found that portions of the elevator control system are not installed in accordance with NFPA-70, and ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

1. The surveyor did not find a single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation of each elevator as required by NFPA-70, Section 620-53.

2. The surveyor did not find that the disconnect for the emergency lighting and controls for each elevator was fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. This deficiency could affect any patients, staff, or visitors in the fire compartment housing the First Floor Imaging Department, because the condition lessens the construction type of the building.

Findings include:

A. At 1:43 PM on March 19, 2013, the construction type of the First Floor (apparent) building addition which houses X-Ray Rooms 1 and 2 was observed to be different than the rest of the building because the roof/ceiling assembly is constructed with open web steel joists and a drywall ceiling membrane in which unsealed penetrations were observed.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of separation could result in delayed response to fire/smoke conditions which compromise the facility's use of the exit access corridors.

The finding is:

A. Morning of 03/19/13 5th floor, The corridor wall located at the south end of the east/west corridor outside of Ambulatory Care does not provide a continuous separation between a use area and an exit access corridor. The wall contains flexible duct penetrations (located above the entry door to Ambulatory Care) which do not provide protection for the transfer of smoke to comply with 19.3.6.4 and NFPA 90 A 1999.

B. Patient care areas were observed open to an exit access corridor. The surveyor questioned if there were any suites within the facility to comply with 19.2.5 and was informed that there were none. The following areas comprise the locations which do not comply with 19.2.5.1:

1. Morning of 03/19/13 4th floor, Recovery

2. Morning of 03/19/13 4th floor, Pre-Op

3. Afternoon of 03/19/13 1st floor, Emergency Department

4. Afternoon of 03/18/13 5th floor, Ambulatory Care - West end of the floor.

C. Afternoon of 03/19/13, 4th floor, the corridor wall located above the north end sliding entry door to Same Day Surgery contains a large hole above the duct penetration which does not maintain a complete barrier to comply with 19.3.6.2.1.

D. Morning of 03/20/13, 2nd floor of South building contains a waiting area with an elevated ceiling. The unsupervised waiting area is open to the means of egress and lacks smoke detection to comply with 39.3.4 and 9.6.2.9 for signal initiation in common areas.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients within the smoke compartment, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. On the morning of 3/19/13, the 4th floor corridor door to Recovery was observed with a roller latch. This hardware installation does not comply with 19.3.6.3.2.

B. On the morning of 3/19/13, the 4th floor corridor sliding doors to Pre-Op (Same Day Surgery) were observed to have the following door hardware:

1. A thumb-turn lock-set which does not comply with 19.2.2.2.9 and 7.2.1.14 (1) for a readily operable door from both sides (the doors are not capable of latching from the corridor side).

2. A releasing device on both sides of the door having an obvious method of operation and readily operable under all lighting conditions which includes no light to comply with 7.2.1.5.4.

C. On the morning of 03/19/13 the 4th floor corridor doors for Operating rooms # 1 - # 4 were observed not to comply with 19.3.6.3.2 for latching hardware.

D. On the morning of 3/19/13, the 4th floor pair of cross corridor doors to 4 A Wing contain a delayed egress mechanism. The facility is not fully sprinkler protected therefore this hardware installation does not comply with 7.2.1.6.

Based on random observation during the survey walk-through, not all floor/ceiling assemblies are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any staff or visitors in the fire compartments housing the deficiencies by permitting smoke or fire to pass between building stories.

Findings include:

A. Pipe penetrations through floor/ceiling assemblies were observed to not be sealed against the passage of fire as required by 8.2.3.2.4.2. Locations observed include:
1. 3:01 PM March 18, 2013: Third Floor South Center IT Room, pipe sleeves at ceiling and floor.

2. 9:15 AM March 19, 2013: Second Floor South Center IT Room, pipe sleeves at ceiling.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. These deficiencies could affect any patients, staff, or visitors in the smoke compartments housing the deficiencies by permitting smoke or fire to pass from the hazardous areas to the rest of the compartment.

Findings include:

A. At 3:11 PM on March 18, 2013, unsealed pipe and other penetrations were observed in the south wall of the Third Floor Center East File Room as prohibited by 39.3.2.1. and 8.2.3.2.4.2.

B. At 10:38 AM on March 19, 2013, the door to the Basement Laboratory Storage Room was observed to not carry a minimum 3/4 hour fire rating as required by 39.3.2.1. and 8.2.3.2.3.1(2).

C. At 2:12 PM on March 18, 2013, the door to the Fifth Floor South Center Soiled Utility Room was observed to be damaged, thus compromising the minimum 3/4 hour fire rating required for the door by 19.3.2.1. and 8.2.3.2.3.1(2).


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D. Afternoon of 03/18/13 5th floor, soiled linen room is not provided with a self closing door to comply with 8.2.3.2.3.1 (2).

E. Afternoon of 03/18/13 5th floor mechanical room adjacent to the Ambulatory Care clinic contains a hole in the east wall which is not sealed to prevent the passage of smoke and fire.

F. Afternoon of 03/18/13 5th floor, Doctor's Office (indicated as a Equipment room on the Life Safety floor plans) contains numerous combustibles. Six shelves were observed which are 4.5 feet long by 2 feet deep. Each shelf contained a minimum of four stacks of papers that are each over 12 inches in height. In addition there are rows of paper stacks and folders which are two feet deep and eight feet in length. This AHJ deems this office as a hazardous area which does not comply with all requirements of 19.3.2.1 for a minimum 1-hour enclosure with a fire rated self closing door.

G. Afternoon of 03/19/13 4th floor, Operating room #4 was observed to contain storage of numerous combustible materials such as pillows, mattress covers, mattress pads and boxed table covers. This room is deemed a hazardous area by this AHJ and does not comply with 19.3.2.1 due to the following:

1. The corridor door is not fire resistant to comply with 8.2.3.2.4.2

2. The corridor door is not self closing to comply with 8.2.3.2.3.1 (2)

3. The room's walls are not indicated on the life safety plans to comply with 8.2.2.2.

H. Afternoon of 03/19/13 1st floor, Emergency Department Bays # 4 - # 6 was observed to contain storage of numerous combustible materials such as pillows, boxed and plastic wrapped medical supplies, gurneys with mattress pads lined up in bays (two in one treatment bay). This area is greater than 100 square feet, not separated from the patient treatment areas and is deemed a hazard by this AHJ. This area does not comply with 19.3.2.1.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any building occupants using the exit stairs because the stair enclosure could be compromised by smoke or fire, or by allowing a condition at which they could fall through the guardrails.

Findings include:

A. At 10:40 AM on March 19, 2013, rooms which are not normally occupied were observed to communicate directly with the Basement level enclosure for the Center East Exit Stair, as prohibited by 7.1.3.2.1(d). Rooms observed to open directly into the Exit Stair include:
1. The Boiler Room.
2. An Electrical Room.
B. At 9:20 AM on March 19, 2013, a series of unprotected windows were observed in the exterior walls of fire rated exit stair enclosures which are adjacent to windows in an exterior wall of the building which is at an angle to the exit stair enclosure wall of less than 180 degrees, as prohibited by 7.2.2.5.2. Locations observed include:
1. Center East Exit Stair: South wall of Fourth Floor.
2. Southwest Exit Stair (all north wall):
a. Fourth Floor.

b. Third Floor.

c. Second Floor.
d. First Floor.

C. At 2:57 PM on March 18, 2013, the distance between guardrails in exit stair enclosures was observed to be in excess of 4" as prohibited by 7.2.2.4.6(3). Exit stair enclosures at which this condition was observed include:

1. Southeast Exit Stair: All levels below the Fifth Floor.
2. Southwest Exit Stair: All levels.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors attempting to use the egress paths because the paths could become restricted.

Findings include:

A. At 9:08 AM on March 19, 2013, the following conditions were observed at the Fifth Floor Center "angled" wall adjacent to the Center Elevator and the Center West Exit Stair:

1. The clear width of the Corridor on both sides of the angled wall was observed to be reduced, as compared to corridor widths at either end of the wall. The angled wall is thus not arranged to avoid an obstruction to the convenient removal of building occupants as required by 19.2.3.3.

2. The door in the angled wall, when in the open (90 degree) position was observed to reduce the Corridor to less than half its required width as prohibited by 7.2.1.4.4.

B. At 10:30 AM on March 20, 2013, the following conditions were observed at the Corridor leading to the Fourth Floor south center portion of the building to the Southeast Exit Stair:
1. The two doors in the fire barrier were observed to not swing in the primary direction of egress as required by 7.2.1.4.2.
2. Because no exit sign was observed above the east face of the eastern-most door cited above, the Corridor between the doors in the east fire barrier and the Southeast Exit Stair constitutes a dead end corridor of excessive length as prohibited by 19.2.5.10.

C. At 10:18 AM on March 20, 2013, the Second Floor Corridor between the doors in the east fire barrier and the Southeast Exit Stair was observed to constitute a dead end corridor of excessive length, as prohibited by 19.2.5.10., because no exit sign was observed above the east face of the eastern-most door in the fire barrier.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the fire compartments on either side of the deficient barriers by permitting smoke or fire to pass between the fire compartments.

Findings include:

A. Doors in designated fire barriers were observed to not be self-closing as required by 8.2.3.2.3.1(1). Locations observed include:
1. 11:15 AM March 19, 2013: Door in fire barrier in middle of Basement Center Tunnel (accessible from Mechanical Room B).

2. East leaf of the First Floor Center pair of fire doors immediately south of Main Conference Room.



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F. On the afternoon of 03/19/13 the 4th floor fire rated cross corridor barrier doors located between 4B and 4A (near the Stair that is not an exit) contain a continuous vertical gap at the meeting stiles which does not comply with NFPA 80 for Standard for Fire Doors and Fire Windows.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect any staff in the Basement Laboratory because the exit access doors could be difficult to locate in emergency conditions.

Findings include:

A. At 10:53 AM on March 19, 2013, the egress paths within the Basement Laboratory were observed to not be identified by exit signs as required by 7.10.1.1. Egress paths observed to not be provided with exit signs include:

1. North door to Corridor.

2. South door to Corridor.

Based on random observation during the survey walk-through, document review, and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect any patients, staff, or visitors in the building because key life safety components could become compromised if not protected.

Findings include:

A. During an interview held in his Office on the afternoon of March 18, 2013, the provider's Hospital's Director of Plant Operations was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 19.7.1.1. Further, during the survey walk-through, it was determined that existing records of such components were inaccurate. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include (but are not necessarily limited to):

1. Occupancy classifications.

2. Fire barriers and their fire resistance ratings, including occupancy separations, horizontal exits, building separations, and separations between disparate construction types.

3. Exit Passageways.

4. Shaft enclosures and their fire resistance ratings, including exit stairs, exit discharge enclosures, elevators, ventilation shafts, and linen and/or refuse chute shafts.

5. Exit access corridors and designated corridor walls.

6. The limits and areas (in square feet) of all suites.

Based on random observation during the survey walk through the surveyor found that not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999). This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

Findings include:

A. The electrical panel at the 24 hour security location has circuits marked as feeding fire alarm that are not marked in red and equipped with a locking device as required by NFPA-72, Section 1-5.2.5.2.

B The Fire Alarm Control Panels are not labeled with the electrical panel designation and circuit number as required by NFPA 72, Section 1-5.2.5.

C. The fire alarm audible device located in the southeast corridor of the fourth floor did not operate when the fire alarm system was activated. The fire alarm was not audible on the third floor in the southeast corridor, on the first floor in the Greenview Health Suite and in other areas of the building in accordance with the 1999 Edition of NFPA-72, Chapter 4.

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:


A. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7.

B. The fire pump was not equipped with a transfer switch at the fire pump location and was not served from the emergency generator to comply with NFPA-20, Section 6.2.

A. Fire damper installation are incomplete or do not exist:

1. On the afternoon of 3/19/13 while in the company of the maintenance technician the surveyor finds access to and verification of fire damper installation is not provided at the following locations.

a. Lower Level Mechanical Room A:
The duct penetration (return or exhaust) through the floor above the air handling unit was not provided with an access panel for service and inspection of the required protection for the penetration. It could not be determined through observation, staff interview or review of the damper inventory that a damper is installed at this penetration.

b. Lower Level Telephone Switch Room:
Supply ducts that penetrate through to the floor above do not have access panels for service or inspection of installed fire or fire/smoke dampers. It could not be determined through observation, staff interview or review of the damper inventory that a damper is installed at these penetrations.

2. On the afternoon of 3/19/13 while in the company of the Hospital's Director of Plant Operations the surveyor finds at the 5th Floor Staff Lounge:

a. The exhaust inlet through the face of the shaft wall is not provided with a fire damper.

b. Observed through the ceiling access door above the ice machine, the installation of a fire damper from a duct penetration from the enclosing shaft for a horizontal run of exhaust duct above the ceiling. The enclosing shaft wall is not complete. Protection is not provided for this duct penetration. This fire damper is not included in the facility's fire damper inventory. ( Comment: Upon review of the 2010 damper inventory it appears to be incomplete for all installed dampers within the facility. The 2010 inspection and servicing report includes only picture of internal duct installations of the individual protecting devises and does not address the barrier penetration and its completeness. Those devises identified as failing in some respect in the 2010 report did not have any indication of the corrective action taken.)

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire to comply with 19.2.3.3. This condition may affect patients staff and visitors on the floor of incident.

The finding is:

A. On the afternoon of 03/19/13 3rd floor exit access corridors were observed being utilized for storage of equipment. Nursing equipment, and computers were observed plugged into and charging from corridor outlets. No staff were observed using the equipment.

A. Emergency Department:

Based on direct observation, the afternoon od 3/19/13 while in the company of the Maintenance Technician, the surveyor finds the facility failed to provide:

1. Separation by an intervening wall the medical gas zone valves and the outlets/inlets they serve for treatment bays 1 thru 6. (NFPA 99, 1999, 4-3.1.2.3 (d)

2. Zone valves for the outlets /inlets in Triage. (NFPA 99, 1999, 4-3.1.2.3 (d)

Based on random observation during the survey walk-through not all medical gas systems comply with with NFPA 99, 1999, Chapter 4. Failure to install and maintained medical gas systems in accordance with referenced standard could result in failure of those systems, while in use or needed for critical patients.

The findings are:

A. On the afternoon of 03/19/13 The 4th floor Surgery area medical gas systems contained a master zone shut off valve located behind a lockable door and within an office. This location does not comply with NFPA 99 1999 chapter 4 for the required access to the shut off valve.

B. On the afternoon of 03/19/13 the 4th floor Operating rooms 1, 2, 3 and 4 each lacked a medical gas shut off valve. The surveyor was informed that the only shut off valve is the master located within the office. Therefore, under an emergency conditions an individual Operating room cannot be shut down without shutting down all Operating rooms. This application does not comply with NFPA 99 1999 chapter 4.

Based on random observation during the survey walk-through, not all smoke barriers are constructed or maintained as fire/smoke resistive assemblies to comply with 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended smoke barrier protection between smoke compartments.

The finding is:

A. On the afternoon of 03/18/13 the 5th floor designated fire/smoke barrier between Wing 5 B and 5 A contained duct penetrations which were not protected against the spread of smoke and fire from one compartment to the adjacent compartment.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches as required by NFPA-70, Section 517-31 thru 35. The system one line diagram was not up to date and it did not show all emergency panels or what branch each transfer switch served, and most panels were not labeled with the branch of emergency power they served. Examples include:

1. Panel E5PH is serving a mixture of all three branches, life safety, critical and equipment.

2. Panel ETS01-5 serves a mixture of life safety and critical, including room receptacles (critical) Section 517-33, and elevator cab lighting that shall be served from life safety in accordance with section 517-32.

3. Panels CP2 and CP3 are new critical panels in the remodeled northeast wings on the second and third floors, and they are serving med gas alarms and emergency lighting which shall be served by the life safety panel to comply with Section 517-32.

4. Panel E2PA did not have enough detail in the circuit description to determine if it was life safety or critical.

5 The panel at the 24 hour security desk was serving life safety (fire alarm), and critical (receptacles), and had no panel identification.

7. Panel EBPA serves a mixture of life safety and equipment.

7. Two panels in the tunnel off of mechanical room B, EBPN and EBPO were labeled as critical panels , but served mostly equipment loads.

Based on random observation during the survey walk-through the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

A. Normal power receptacles were not provided in operating rooms on the fourth floor as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

B. Bonding of the piping for the gas system could not be located by staff as required by NFPA-70, Section 250-104(b). This could cause a potential difference between gas piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

C. The water meter was not equipped with a bonding jumper to comply with NFPA-70, Section 250-50(a)(1).

D. Emergency receptacles in the operating rooms on the fourth floor, and other patient bed locations were not labeled with the source panel and the circuit number in accordance with NFPA-70, Section 517-19(a). This could cause confusion during a power outage trying to locate an emergency receptacle for critical care equipment.

E. Patient bed location on the third floor in wing A were not equipped with emergency receptacles as required by NFPA-70, Section 517-18. This could effect any patient in this wing in the event of a power outage.

F. Panels in several location, including panels 5JP, 5PG, E4PK, E2PA, and several other locations, were either missing schedules or the schedules needed to be updated to comply with NFPA-70, Section 110-22. Schedules were handwritten, breakers were on but marked as spares or not labeled at all, and some panels including the panel at the 24 hour security desk and the emergency panel in the mechanical room 4 were not identified.