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During the survey at approximately 1235 hours on February 2, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that in the short hall near the Decon Room on the ground floor there were two penetrations, approximately 12" X 15" and 24" x 20", in the walls near the underside of the floor above which will allow the passage of smoke and by-products of combustion to the egress corridor and other areas of the building. These penetrations are above the ceilings and through the two walls which separate the short hall from the Cafe and the Decon Room.

During the survey on February 2, 2016 at approximately 1220 hours it was observed and confirmed through interview with the Facilities and Construction Manager that the Medical Records Storage Room on the ground floor one of two egress doors is not equipped with a listed and fire-rated self-closing device as required. This room is greater than 50 sq. ft. (approx. 20' X 36') in area and is used to store an large amount of combustibles (open paper records on shelves).

1) During the survey at approximately 1325 hours on February 1, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that there are two egress doors to the corridor from the Pharmacy on the 6th floor that are each equipped with two single cylinder dead bolt locks (101-7.2.1.5.4, 2000 ed.)

2) During the survey at approximately 1100 hours on February 2, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that within the exit stairway by room #266 there is an access door to an electrical room which is only accessible from this stairway (101-7.1.3.2.1(d), 2000 ed., also see CMS S&C memo #13-58 Item #2)

3) During the survey at approximately 1150 hours on February 2, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that the inner set of 1st floor Emergency Department egress doors at the ambulance entrance (a set of powered doors) is a equipped with a single cylinder dead bolt lock assembly with a thumb turn on the interior side of the lock assembly. The thumb turn, lock cover, and door frame are all finished in the same dark color. The door assembly is provided with signs stating "In Emergency-Push to Open". When the dead bolt lock is in the 'locked' position the doors will not "push" to break away and open in an emergency as indicated. The lock thumb turn shall be a contrasting color to be readily visible under all lighting conditions and instructions indicating the method of operation to unlock the doors shall be posted adjacent to the lock.

1) During the survey on February 1, 2016 at approximately 1310 hours it was observed and confirmed through interview with the Facilities and Construction Manager that within the OTC storage area of the Pharmacy on the 6th floor there are four quick response and 2 standard response automatic sprinkler heads located within the same room.

2) During the survey on February 2, 2016 at approximately 1305 hours it was observed and confirmed through interview with the Facilities and Construction Manager that the five walk in coolers and freezers within the kitchen are not automatic sprinkler protected. All other areas of the kitchen are provided with automatic sprinkler protection.

1) During the survey on February 1, 2016 between 0930 hours and 1230 hours it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Facilities and Construction Manager that the required inspection, testing and maintenance (ITM) of the building standpipe system was overdue. The Facilities and Construction Manager was not able to produce any records related to the required annual ITM of the automatic sprinkler system for 2015.

Reports showing completion of the required inspections, tests, maintenance, and any required service (repairs) related to these systems shall be forwarded to this surveyor. These suppression system components shall be included in the facility's ongoing testing and maintenance programs/contracts.

2) During the initial survey on February 1, 2016 between 0930 hours and 1230 hours it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Facilities and Construction Manager that the required pressure gauges for the building standpipe system risers were not installed. The lack of these pressure gauges was noted on inspection reports from the facility's vendor which were reviewed during the survey.

During the survey between approximately 0930 hours and 1230 hours on February 1, 2016 through a review of the facility's documents, observation of the physical environment, and interview with the Facilities and Construction Manager it was determined that the facility failed to meet the building fire alarm system interconnection requirement for the kitchen hood extinguishing system as required in NFPA 96, 1998 edition, Chapter 10-6.


Note- Last semi-annual test and service of kitchen hood extinguishing system was on 08/11/2015 by BFPE.

At approximately 1105 hours on February 2, 2016 during this survey it was observed and confirmed through interview with the Facilities and Construction Manager that there was a "glowing coil" type portable electric space heater, not plugged in, located under a desk in the 2nd floor IT Office. This portable electric space heater was observed to have a heat damaged electric plug on the power cord. The heater was removed immediately by facility staff at the direction of this surveyor.

During the survey on February 2, 2016 at approximately 1130 hours it was observed and confirmed through interview with the Facilities and Construction Manager that the 2nd Floor egress corridor in the Sleep Disorder area at Sleep Rooms # 2 was obstructed to less than the full clear and usable width. The corridor obstructions included 5 chairs, a loveseat, and a table. These items were observed to be left in the egress corridor in excess of thirty minutes (see CMS S & C memos 12-21 and 13-58).

1) At approximately 1115 hours on February 2, 2016 during this survey it was observed and confirmed through interview with the Facilities and Construction Manager that in the IT Storage area (Old C-Section Room) on the 2nd floor there was a 1 cubic yard capacity (173.5 gallons) wheeled trash container filled with cardboard boxes. This storage area does not comply with hazardous area requirements of the Code as required.

2) At approximately 1205 hours on February 2, 2016 during this survey it was observed and confirmed through interview with the Facilities and Construction Manager that at the Lab/Loading Dock area on the 1st floor there were two 8 cubic feet capacity (51 gallons each) wheeled trash carts. This storage area does not comply with hazardous area requirements of the Code as required.

3) At approximately 1245 hours on February 2, 2016 during this survey it was observed and confirmed through interview with the Facilities and Construction Manager that in the Kitchen Dish Room on the ground floor there were two wheeled trash containers with a capacity greater than 32 gallons. This storage area does not comply with hazardous area requirements of the Code as required.

During the survey on February 2, 2016 at approximately 1310 hours it was observed and confirmed through interview with the Facilities and Construction Manager that in the 1st floor Warehouse there is a medical gas storage room. This room was observed to contain 80 "E" size oxygen cylinders and 14 "H" size medical gas cylinders containing various gases including oxygen. Observed non-compliance includes:

a) One "E" cylinder was freestanding on the floor not secured in a rack or stand as required.
b) The egress door from this medical gas storage room is not equipped with a fire rated and listed self-closing device as required.
c) This medical gas storage room is not identified with the required signs.
d) This medical gas storage room is not equipped with mechanical or natural ventilation as required. The total capacity of gas cylinders observed to be stored in this room is approximately 5500 cubic feet.
e) This medical gas storage room was observed to also be used for storage of flammable liquids, specifically there were 2 cases of Isopropyl Alcohol (containing 60- four oz. plastic bottles each) and 2 cases of SP Methyl Alcohol (containing 7- one gallon plastic jugs total) in a flammable liquids storage cabinet.

2) During the initial survey on February 2, 2016 at approximately 1320 hours it was observed and confirmed through interview with the Facilities and Construction Manager that in the 1st floor Warehouse there are medical gas cylinders stored in a non-compliant manner. These medical gas cylinders were observed to be 8 "H" size medical gas cylinders stored in the open, chained to a wall, in the loading dock area of the warehouse. These total capacity of these medical gas cylinders is approximately 2000 cubic feet. The storage of these cylinders in this manner lacks the required:
a) Separation to other areas.
b) Identification of the medical gas storage area.

1) During the survey at approximately 1305 hours on February 1, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that in the Pharmacy Employee Lounge on the 6th floor there was a 2 slice toaster, a microwave oven, and a coffee maker all plugged into a 15 amp rated multi outlet extension cord that was plugged into a 120 VAC wall outlet.

2) During the survey at approximately 1320 hours on February 1, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that in the Pharmacy on the 6th floor there was an oil filled portable electric space heater and three IT devices all plugged into a 15 amp rated multi outlet extension cord.

3) During the survey at approximately 1330 hours on February 1, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that in the Central Sterile area on the 6th floor there was a 2 slice toaster and a microwave oven plugged into a 15 amp rated multi outlet extension cord that was plugged into a 120 VAC wall outlet.

4) During the survey at approximately 1400 hours on February 1, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that in the Break Room at the Nurses Station on the 3rd floor that two of two 120 VAC wall receptacles are not ground fault circuit interrupter (GFCI) protected as required. One of these receptacles is less than 4 feet from a sink with running water.

During the survey at approximately 1235 hours on February 2, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that in the short hall near the Decon Room on the ground floor there were two penetrations, approximately 12" X 15" and 24" x 20", in the walls near the underside of the floor above which will allow the passage of smoke and by-products of combustion to the egress corridor and other areas of the building. These penetrations are above the ceilings and through the two walls which separate the short hall from the Cafe and the Decon Room.

During the survey on February 2, 2016 at approximately 1220 hours it was observed and confirmed through interview with the Facilities and Construction Manager that the Medical Records Storage Room on the ground floor one of two egress doors is not equipped with a listed and fire-rated self-closing device as required. This room is greater than 50 sq. ft. (approx. 20' X 36') in area and is used to store an large amount of combustibles (open paper records on shelves).

1) During the survey at approximately 1325 hours on February 1, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that there are two egress doors to the corridor from the Pharmacy on the 6th floor that are each equipped with two single cylinder dead bolt locks (101-7.2.1.5.4, 2000 ed.)

2) During the survey at approximately 1100 hours on February 2, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that within the exit stairway by room #266 there is an access door to an electrical room which is only accessible from this stairway (101-7.1.3.2.1(d), 2000 ed., also see CMS S&C memo #13-58 Item #2)

3) During the survey at approximately 1150 hours on February 2, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that the inner set of 1st floor Emergency Department egress doors at the ambulance entrance (a set of powered doors) is a equipped with a single cylinder dead bolt lock assembly with a thumb turn on the interior side of the lock assembly. The thumb turn, lock cover, and door frame are all finished in the same dark color. The door assembly is provided with signs stating "In Emergency-Push to Open". When the dead bolt lock is in the 'locked' position the doors will not "push" to break away and open in an emergency as indicated. The lock thumb turn shall be a contrasting color to be readily visible under all lighting conditions and instructions indicating the method of operation to unlock the doors shall be posted adjacent to the lock.

1) During the survey on February 1, 2016 at approximately 1310 hours it was observed and confirmed through interview with the Facilities and Construction Manager that within the OTC storage area of the Pharmacy on the 6th floor there are four quick response and 2 standard response automatic sprinkler heads located within the same room.

2) During the survey on February 2, 2016 at approximately 1305 hours it was observed and confirmed through interview with the Facilities and Construction Manager that the five walk in coolers and freezers within the kitchen are not automatic sprinkler protected. All other areas of the kitchen are provided with automatic sprinkler protection.

1) During the survey on February 1, 2016 between 0930 hours and 1230 hours it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Facilities and Construction Manager that the required inspection, testing and maintenance (ITM) of the building standpipe system was overdue. The Facilities and Construction Manager was not able to produce any records related to the required annual ITM of the automatic sprinkler system for 2015.

Reports showing completion of the required inspections, tests, maintenance, and any required service (repairs) related to these systems shall be forwarded to this surveyor. These suppression system components shall be included in the facility's ongoing testing and maintenance programs/contracts.

2) During the initial survey on February 1, 2016 between 0930 hours and 1230 hours it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Facilities and Construction Manager that the required pressure gauges for the building standpipe system risers were not installed. The lack of these pressure gauges was noted on inspection reports from the facility's vendor which were reviewed during the survey.

During the survey between approximately 0930 hours and 1230 hours on February 1, 2016 through a review of the facility's documents, observation of the physical environment, and interview with the Facilities and Construction Manager it was determined that the facility failed to meet the building fire alarm system interconnection requirement for the kitchen hood extinguishing system as required in NFPA 96, 1998 edition, Chapter 10-6.


Note- Last semi-annual test and service of kitchen hood extinguishing system was on 08/11/2015 by BFPE.

At approximately 1105 hours on February 2, 2016 during this survey it was observed and confirmed through interview with the Facilities and Construction Manager that there was a "glowing coil" type portable electric space heater, not plugged in, located under a desk in the 2nd floor IT Office. This portable electric space heater was observed to have a heat damaged electric plug on the power cord. The heater was removed immediately by facility staff at the direction of this surveyor.

During the survey on February 2, 2016 at approximately 1130 hours it was observed and confirmed through interview with the Facilities and Construction Manager that the 2nd Floor egress corridor in the Sleep Disorder area at Sleep Rooms # 2 was obstructed to less than the full clear and usable width. The corridor obstructions included 5 chairs, a loveseat, and a table. These items were observed to be left in the egress corridor in excess of thirty minutes (see CMS S & C memos 12-21 and 13-58).

1) At approximately 1115 hours on February 2, 2016 during this survey it was observed and confirmed through interview with the Facilities and Construction Manager that in the IT Storage area (Old C-Section Room) on the 2nd floor there was a 1 cubic yard capacity (173.5 gallons) wheeled trash container filled with cardboard boxes. This storage area does not comply with hazardous area requirements of the Code as required.

2) At approximately 1205 hours on February 2, 2016 during this survey it was observed and confirmed through interview with the Facilities and Construction Manager that at the Lab/Loading Dock area on the 1st floor there were two 8 cubic feet capacity (51 gallons each) wheeled trash carts. This storage area does not comply with hazardous area requirements of the Code as required.

3) At approximately 1245 hours on February 2, 2016 during this survey it was observed and confirmed through interview with the Facilities and Construction Manager that in the Kitchen Dish Room on the ground floor there were two wheeled trash containers with a capacity greater than 32 gallons. This storage area does not comply with hazardous area requirements of the Code as required.

During the survey on February 2, 2016 at approximately 1310 hours it was observed and confirmed through interview with the Facilities and Construction Manager that in the 1st floor Warehouse there is a medical gas storage room. This room was observed to contain 80 "E" size oxygen cylinders and 14 "H" size medical gas cylinders containing various gases including oxygen. Observed non-compliance includes:

a) One "E" cylinder was freestanding on the floor not secured in a rack or stand as required.
b) The egress door from this medical gas storage room is not equipped with a fire rated and listed self-closing device as required.
c) This medical gas storage room is not identified with the required signs.
d) This medical gas storage room is not equipped with mechanical or natural ventilation as required. The total capacity of gas cylinders observed to be stored in this room is approximately 5500 cubic feet.
e) This medical gas storage room was observed to also be used for storage of flammable liquids, specifically there were 2 cases of Isopropyl Alcohol (containing 60- four oz. plastic bottles each) and 2 cases of SP Methyl Alcohol (containing 7- one gallon plastic jugs total) in a flammable liquids storage cabinet.

2) During the initial survey on February 2, 2016 at approximately 1320 hours it was observed and confirmed through interview with the Facilities and Construction Manager that in the 1st floor Warehouse there are medical gas cylinders stored in a non-compliant manner. These medical gas cylinders were observed to be 8 "H" size medical gas cylinders stored in the open, chained to a wall, in the loading dock area of the warehouse. These total capacity of these medical gas cylinders is approximately 2000 cubic feet. The storage of these cylinders in this manner lacks the required:
a) Separation to other areas.
b) Identification of the medical gas storage area.

1) During the survey at approximately 1305 hours on February 1, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that in the Pharmacy Employee Lounge on the 6th floor there was a 2 slice toaster, a microwave oven, and a coffee maker all plugged into a 15 amp rated multi outlet extension cord that was plugged into a 120 VAC wall outlet.

2) During the survey at approximately 1320 hours on February 1, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that in the Pharmacy on the 6th floor there was an oil filled portable electric space heater and three IT devices all plugged into a 15 amp rated multi outlet extension cord.

3) During the survey at approximately 1330 hours on February 1, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that in the Central Sterile area on the 6th floor there was a 2 slice toaster and a microwave oven plugged into a 15 amp rated multi outlet extension cord that was plugged into a 120 VAC wall outlet.

4) During the survey at approximately 1400 hours on February 1, 2016 it was observed and confirmed through interview with the Facilities and Construction Manager that in the Break Room at the Nurses Station on the 3rd floor that two of two 120 VAC wall receptacles are not ground fault circuit interrupter (GFCI) protected as required. One of these receptacles is less than 4 feet from a sink with running water.