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Based on random observation during the survey walk through, accompanied by facility staff, the surveyor finds that a non conforming building is not separated from the health care occupancy by two hour rated construction as required by 19.1.1.4.1. This deficiency could affect the patients, staff, and visitors within the building in the event of a fire in the non conforming building.

Findings include:

A. At 9:20 AM on April 17, 2014, in the Basement, it was observed that the Loading Dock is not separated from areas of the Basement that are required by 19.1.6.1 to be protected construction. There is an unrated overhead door in the masonry wall that separates the Type I (332) Loading Dock area and the adjacent Type II (000) Autoclave Room Addition. 8.2.3.2.1

Based on observation during the survey walk-through while accompanied by the facility staff it was observed that components of the buildings designated construction type do not comply with, 19.1.6.2, and NFPA 220, 1999 Edition. This condition could affect individuals on the floor of fire incident from safely traveling the means of egress to the nearest exit.
Finding include:

A. Portions of the Hospital contain unprotected steel which does not comply with the minimum construction type requirements of 19.1.6.2. Example locations include:

1. 04/17/14 at 10:00 am 1st floor Solarium contains large unprotected steel beams. Location observed is the juncture of two corridors north of the Solarium. One leads from the E.D. The other from the Care Unit suite. Both have unprotected steel beams. These corridors meet at the North West corner outside of the Solarium.

2. 04/17/14 at 10:00am 1st floor Solarium contains unprotected steel tube columns (viewed above the suspended acoustical tile ceiling) location observed within the lower ceiling part of Solarium toward the skylight area.




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B. At 10:15 AM on April 16, 2014, on the First floor it was observed that combustible materials were used to build interior elements within the Solarium area, which does not comply with NFPA 220 1999 3-1. Locations include:

1. The decorative ceiling framing in the Cardiac Waiting Room was observed to be constructed of painted 2x lumber.

2. The ceiling over the alcove at the fire rated doors between the Cardiac Waiting Room and the corridor was observed to have plywood at the top. This assembly was indicated to be a part of a 2 hour separation assembly and a UL design was not provided.

Based on random observation during the survey walk through and staff interview, accompanied by facility staff, the surveyor finds that not all corridor wall finishes are in compliance with 10.2.3 and 19.3.3.2. During a fire/smoke emergency, this deficiency could affect all occupants from the exit stair and smoke compartment due to possible exposure to smoke producing materials.

Findings include:

A. At 9:33 AM on April 16, 2014, on the First floor, the walls in the corridor and stair lobby adjacent to the Business and Home Care Offices were observed to be covered with a material that was indicated to be jute. Documentation that this material has a Class A or Class B rating was not provided. 19.3.3.2

Based on random observation during the survey walk through, accompanied by facility staff, the surveyor finds that not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect any patients, staff, or visitors in the immediate area by permitting smoke to enter the egress corridor.

Findings include:

A. At 3:05 PM on April 15, 2014, on the First floor, the Men ' s Changing Room located near the Cat Scan Room, which is not constantly attended and which is observed to be open to the adjacent corridor, was observed to lack smoke detectors required by Subpart (c) of Exception 1 to 19.3.6.1.

B. At 3:00 PM on April 15, 2014, on the First floor, the Waiting Room and the Women ' s Waiting Room, located near the Cat Scan Room, which are not constantly attended and which were observed to be open to the adjacent corridor, were observed to lack smoke detectors required by Subpart (c) of Exception 2 to 19.3.6.1.

C. At 1:08 PM on April 16, 2014, in the Basement, it was observed that the corridor door at the Mechanical Room near the Wound Care Department is penetrated by a transfer grille, which is prohibited by 19.3.6.4.

D. At 1:15 PM on April 16, 2014, in the Basement, it was observed that the corridor walls at the Electrical Room and the Elevator Equipment Room near the Trash Chute Room are penetrated by transfer grilles, which is prohibited by 19.3.6.4

Based on observation during the survey walk-through while accompanied by facility staff, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients in the locations 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 occupied rooms.

Findings include:

A. At 9:25am on 04/16/14 2nd floor corridor doors to several suites have hardware which do not provide latching in order to comply with 19.3.6.3.2. Example locations include:

1. Assessment Suite (pair of doors to East corridor)

2. Phase II Recovery Suite (pair of doors to South corridor)

3. Phase I Recovery Suite (pair of doors to South corridor)

4. Phase I Recovery Suite (pair of doors to North corridor)



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B. At 2:57 PM on April 15, 2014, on the First floor, it was observed that the corridor door at the Fluoroscopy Room in the Radiology Department is not equipped with positive latching hardware as required by 19.3.6.3.2.

Based on random observation during the survey walk-though, accompanied by facility staff, the surveyor finds that not all shafts are enclosed with fire rated construction as required by 19.3.1.1. This deficiency could affect patients, staff and visitors in the event of a fire on a different floor.

Findings include:

A. At 2:55 PM on April 15, 2014, on the First floor, it was observed that an abandoned duct shaft in the X-Ray Film Developing Room is sealed at the bottom with sheet metal. It could not be determined if the required fire rating was intact above this material, and the room is not indicated to be of fire rated construction as required by 8.2.5.3

Based on observation during the survey walk-through, while accompanied by facility staff the means of egress to the public way is not apparent to comply with 19.2.10.1, 7.2.2.5.4 and 7.10.1.4. In the event of a fire/smoke condition any staff , patients and visitors present, may be unable to determine the most direct route to the level of exit discharge.

The finding is as follows:

A. On 04/15/14 at 11:30am in 4th floor Stair # 1 (North Stair) lacks any signage which will provide orientation and the level of exit discharge to comply with 7.2.2.5.4. This condition was observed in multiple exit stairs within the facility.

First Floor:

A. By direct observation the afternoon of 4/16/14 while in the company of the Manager of
Facilities the surveyor finds:
Above the ceiling by the cross corridor fire doors by the Respiratory Care Offices an installed fire damper in the smoke barrier above the corridor ceiling on the dietary side of the corridor. The above ceiling corridor space is used as a return air plenum for ventilation from the Respiratory Care Offices in non-compliance with NFPA 101, 19.3.7.3.

Based on observation during the survey walk-through,while accompanied by facility staff not all hazardous areas are separated from the remainder of the building to comply with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. 04/15/14 at 1:15 pm 1st floor Linen storage (located adjacent to Clean Linen within the corridor north of Dietary) contains an interior finish of wood paneling whch does not comply with 8.4.1.

B. 04/15/14 at 3:00PM 1st floor Clean Linen contains a corridor access door with a transfer grille which does not comply with 19.3.6.4.

C. 04/17/14 at 9:10am 1st floor Storage room adjacent to the exterior exit from the Dining Room. The room is not designed for storage to due to the following:

1. Louvers located in the South wall and entry door are open to the adjacent exterior sidewalk used for exit discharge from the Dining room and Stair # 2 (from Endo).

2. The room did not appear to be sprinkler protected.

3. The room did not appear to have a fire rated separation from the Dining room.

D. 04/17/14 at 9:00 am Basement Tunnels and Crawl spaces - There are underground spaces under the Hospital. Portions of these space are used as storage spaces. These spaces are not sprinklered and are not separated from other portions of the underground spaces (crawl spaces).


E. 04/16/14 at 9:00am 2nd floor Medgas Storage closet located in an Elevator Lobby east of Outpatient Surgery. This closet contains a pair of doors, one is not self closing.

Based on random observation during the survey walk-though, accompanied by facility staff, the surveyor finds that not all floors of the building have sufficient access to exits that terminate at an exterior exit discharge as required by 19.2.4.1. These deficiencies could affect patients, staff, and visitors on the cited floors in the event of an emergency evacuation.

Findings include:

A. In the morning of April 17, 2014, it was observed that more than 50% of the exit stairs that serve floors 3, 4, and 5 discharge on the level of exit discharge, which does not comply with 7.7.2. Locations observed include:

1. 5th floor - both exit stairs discharge internally.

2. 3rd and 4th floors - three of five exit stairs discharge internally.

Based on observation during the survey walk-through while accompanied by facility staff, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit discharge from the building.

Findings include:

A. At 1:15pm on 04/17/14 1st floor North exit stair from Surgery (discharge is interior North of Diatary) it was observed that conduit penetrations below the stair landing were not sealed to comply with NFPA 101-2000, 8.2.3.2.4.2.



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B. In the morning of April 15, 2014, on the Fourth floor, it was observed that the roofs of the exit stairs near the elevator (Stair 3) and at the north end of the north wing (Stair 1) are equipped with roof hatches that are intended to permit upward expansion of the stairs and so form the roof of the stair towers. The hatches do not maintain the stair enclosure as required by 7.1.3.2.1 as follows:

1. These hatches are not fire rated and do not have the 1 ½ hour protection required for roofs.

2. The hatches have not been maintained so are not weather or smoke tight. In the event of a fire smoke could be drawn into the stairs by the pressure differential created by the gaps in the hatches

3. Rain could enter the stair tower through the gaps in the hatch assembly and compromise the walking surfaces below.

Based on random observation during the survey walk-though, accompanied by facility staff, the surveyor finds that exit access is not arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the building.

Findings include:

A. At 1:35 PM on April 15, 2014, on the Second floor, the corridor that connects the Surgery Department with the ICU Suite has exit signage that directs the path of egress from the corridor into the ICU suite, which is an intervening room. Without a means of egress at the west end of this corridor a dead end of approximately 80 feet is created. 19.2.5.9

B. At 9:00 AM on April 16, 2014, on the First floor, it was observed that the corridor door at IS 2 in the Open Heart Department is equipped with a deadbolt lock that requires a key to operate from both sides. 19.2.2.2.4

C. At 9:20 AM on April 16, 2014, on the First floor, it was observed that a padlock is used to secure the door of the Gift Shop at the Lobby area, which does not comply with 39.2.2.2.1. There is no other path of egress from the Gift Shop that does not pass through a storage room, which does not comply with 7.5.2.1.

D. At 8:50 AM on April 17, 2014, in the Basement, it was observed that a Pharmacy corridor door marked with exit signage is locked on the egress side with an electric strike that is opened from a remote switch, and so cannot be opened readily without special knowledge. 7.2.1.5.1

E. At 10:57 AM on April 16, 2014, in the Basement, it was observed that the door in the horizontal exit between the main Hospital and the adjacent Professional Building is equipped with hardware that can be locked from the Professional Building side against Hospital egress. 19.2.2.2.4

F. At 11:13 AM on April 16, 2014, in the Basement, it was observed that the corridor door at the Mechanical Room located near the Hyperbarics Room is equipped with a magnetic lock. It could not be determined if it is functional or under which conditions it would be locked or unlocked. 19.2.2.2.4

Based on random observation during the survey walk-through while accompanied by the Facility Staff, not all designated suites comply with 19.2.5 concerning the remotely located exit access doors. This condition may affect patients, staff and visitors during a fire emergency by increasing the amount of time and travel distance required to reach an exit access corridor.

Finding includes:

A. On 04/16/14 at 10:10am 2nd floor, Assessment Suite; exit access to a corridor is not indicated from the East pair of doors. This condition does not comply with 19.2.5.3 for two remotely located means of egress.

Based on random observation during the survey walk-through while accompanied by facility representatives, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all patients, visitors and staff within the areas of the fire compartment, as well as any persons in the adjacent compartment, because failure to construct and maintain fire resistive assemblies could allow fire and smoke to pass from one compartment into adjacent fire/smoke compartments.

Findings include:

A. 04/16/14 at 1:45PM 1st floor adjacent to Diatary contains a pair of cross corridor doors within a designated 2 hour barrier wall. The wall (above the pair of doors) contains a duct penetration which lacks an access panel for a required fire damper.

B. 04/15/14 at 2:30pm 2nd floor "center" mechanical room adjacent to Surgical Waiting contains an unprotected steel beam as part of a designated 2-hour enclosure. The beam is located within the barrier wall behind the roof hatch ladder.

Based on random observation during the survey walk-through while accompanied by Facility Staff, battery powered emergency illumination is not provided to comply with 19.2.9.1, 7.9 and NFPA 99-1999, 3-3.2.1.2 for locations of anesthetized patients. This deficiency could affect any patients, and staff due to any failure with normal lighting which could prevent them from safely exiting the building under fire conditions.

Findings include:

A. During the survey walk through, battery powered emergency lighting was not provided to comply with NFPA 99-1999, 3-3.2.1.2(a)5(e). Example locations as follows:

1. 04/16/14 at 1:12pm 2nd floor C-Section Operating room. During an interview held with the Nurse Manager for the OB Dept. it was determined that none of the C-Section Rooms contained battery powered emergency lighting.

2. 04/16/14 at 1:15pm 2nd floor Endoscopy rooms

3. 04/16/14 at 1:18pm 2nd floor "Eye" Operating rooms

4. 04/16/14 at 1:25pm 2nd floor Phase I Recovery

5. 04/16/14 at 1:30pm 2nd floor Phase II Recovery



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6. 04/16/14 at 8:50am 1st floor Cardiac Cath Lab 3 was observed to not contain battery powered emergency lighting.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress to comply with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit during a fire or smoke event.

Findings include:

A. Exit signs are not provided to identify the 2nd means of egress from corridors to comply with 19.2.5.9. Locations noted include the following:

1. On 04/16/14 at 2:45pm 2nd floor corridor East of Assessment Suite was observed to lack a means to identify both egress paths in order to comply with 18.2.5.9. a single exit sign was observed leading to the Endo Corridor.

Based on random observation during the survey walk through while accompanied by the Electrical Contractor and the Plant Operations Secretary, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA-72. This could affect all occupants of the building if the fire alarm system did not operate properly during a fire emergency.

Findings include:

A. The fifth floor west machine room did not have a smoke detector near the fire alarm panel to meet the requirements of NFPA-72, Section 1-5.6.

B. Panel ELL1A in wiring closet #9 had a circuit breaker serving a fire alarm panel that was not marked in red and was not equipped with a circuit breaker lock to meet the requirements of NFPA-72, Section 1-5.2.5.2.



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C. 04/16/14 during testing of the fire alarm system, the visual and audible notification devices did not operate in a manner to give warning in accordance with NFPA 72 4-4. Locations and conditions include:

1. Second floor Endo suite, surveyor was unable to hear any audible devices anywhere within this suite.

2. Second floor assessment, surveyor was unable to hear an audible device within the area.

3. Second floor Phasr I and Phase II Recovery lacks a visual notification device.



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4. Fourth floor Nurses' Station, it was observed that the audible signal was not readily discernable over the ambient noise.

D. At 10:57 AM on April 16, 2014, in the Basement, it was observed that the horizontal exit between the main Hospital and the adjacent Professional Building is not provided with a fire alarm pull station within 5 feet of the door as required by 9.6.2.3 and NFPA 72 1999 2-8.2.2.

Based on random observation during the survey walk, while accompanied by facility staff, failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors. The installation does not comply with NFPA 13 1999

Basement:

By direct observation while in the company of the Manager of Facility's the surveyor finds the:

A. Morning of 4/16/14, the Electrical B3 is not provided with sprinkler protection and does not qualify for the exception for elimination of sprinkler protection as listed in NFPA 13, 1999, 5-13.11. The room is not dedicated to electrical equipment and contains building systems pneumatic control compressors.

B. Afternoon of 4/16/14, the Electrical Room B5 is not provide with sprinkler protection and does not qualify for the exception for elimination of sprinkler protection as listed in NFPA 13, 1999, 5-13.11. The room enclosure lacks sealing of pipe/conduit penetrations and rated doors in the barrier separating the electrical room and the room containing the batteries for the UPS and various pipe supplies.

C. Afternoon of 4/16/14, the access through Storage B6 to the Crawl Space is being used for storage of plumbing supplies. This Crawl Space is not provided with sprinkler protection.

D. Morning of 4/17/14, the hydraulic equipment room and associated shaft for Elevators 20 & 21 are not provided with sprinkler protection as required by NFPA 13, 1999, 5-13.6.





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E. 04/16/14 2:15pm 2nd floor "Center" Mechanical room located between Stair # 3 and Surgery Waiting contained a sprinkler pipe improperly anchored to the bottom of a duct. The pipe was observed to be shaking due to vibration from the duct.


F. 04/16/14 at 9:10am 2nd floor Assessment suite contains 3 Linen Closets (within the main aisle) which lack sprinkler protection

G. 04/15/14 at 10am 4th floor closet located ina corridor alcove leading to Nurse Manager office contains stored items including a blue duffel bag along with multiple shelves with plastic wrapped items. This closet lacks sprinkler protection.

H. 04/16/14 at 1:45pm 2nd floor corridor closet adjacent to Surgery Break room and across the corridor from Phase I Recovery suite contains numerous combustible items and lacks sprinkler protection.



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I. At 9:05 AM on April 17, 2014, in the Basement, it was observed that the morgue cooler lacks sprinkler protection as required by NFPA 13 1999 5-1.1(1).

J. At 9:25 AM on April 17, 2014, in the Basement, it was observed that the Boiler Operator's Office located in the Autoclave Room addition lacks sprinkler protection as required by NFPA 13 1999 5-1.1(1)

Based upon random observation during the survey walk through while accompanied by Facility Staff the surveyor finds that HVAC systems do not comply with NFPA 90A 1999 and/or ASHRAE.

Findings include:

A. 04/16/14 at 1:15pm 2nd floor "Center" mechanical room adjacent to Surgery Waiting room contains a fire damper and/or combination damper that is not installed within the plane of the fire barrier. A damper is installed well beyond the plane of the 2-hour fire/smoke barrier. A built out angled gypsum board box is constructed out from the barrier wall. A duct penetrates it having an access panel and damper installation at the face of the angled box. This installation does not comply with the damper manufacturer's requirements and/or NFPA 90A.

B. 04/16/14 at 1:15pm 2nd floor "Center" mechanical room adjacent to Surgery Waiting and a corridor. The 2-hour barrier above the corridor entry door contains duct penetrations. The ducts lack damper installations and access panels to comply with NFPA 90A.

1. The same barrier is incomplete above the duct penetrations with only sheet metal forming the barrier from the top of the duct to the underside of the deck above. Therefore the ducts are improperly supported which does not comply with NFPA 90A 2-3.1.4

2. The same barrier contains a duct penetration with a dampered transfer grille which does not comply with 19.3.6.4. The duct penetration is located in the area above the entry door.

C. 04/15/14 at 1:30pm 2nd floor maintenance staff corridor (north of Surgery) access provided from 1st floor Mechanical stair adjacent to Respratory Therapy and north Diatary corridor. An overhead duct penetrates the designated 2-hour barrier wall at the second floor staff corridor which lacks a damper and access panel.

Based on random observation during the survey walk through, while accompanied by facility staff, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. This deficient practice may compromise the prompt care and movement of occupants from the 4th, 3rd, and 2nd floor North Stair along with persons within Diatary during a fire/smoke emergency.

Findings include:

A. Means of egress corridors are not maintained free of obstructions to comply with 7.1.10. Locations/conditions observed include:

1. 04/16/14 at 1:50pm 1st floor exit access corridor North of Diatary is utilized for storage of linen carts. The amount of carts stationed within the corridor provide an obstruction for the means of egress from Stair #1 (from Surgery).

2. 04/16/14 at 1:50pm 1st floor exit access corridor North of Diatary is utilized for storage of plastic cartons which are stacked up at the location where the corridor width diminishes. The cartons stationed within the corridor provide an obstruction with in the means of egress.

3. 04/16/14 at 2:30pm 1st floor exit access corridor adjacent to Diatary Offices is utilized for storage of linen carts. The carts are stationed within the corridor reduce the required width of the corridor and block access to a pair of cross corridor doors within the means of egress.

Based on random observation during the survey walk through while accompanied by the Maintenance Electrician, (on the first day of the survey), and the Electrical Contractor, (on the second day of the survey), and the Plant Operations Secretary, the surveyor found that the emergency electrical system installation did not meet all requirements of NFPA-70, NFPA-99, and NFPA-110. This could affect any occupant of the facility if a transfer switch fails and all branches of emergency power and normal power are lost are lost.

Findings include:

A. It was observed that the original hospital was not equipped with a separate transfer switch for each branch of emergency power as required by NFPA-70, Section 517-30.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the
survey walk-through, the provider shall institute the 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 while accompanied by the Electrical Contractor and the Plant Operations Secretary, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. Emergency power for the original hospital is not separated into three branches as required by NFPA-70, Section 517-30 through 517-35. All 120-208 volt load is served from a single transfer switch and it was observed that the panels served from this transfer switch were a mixture of life safety, critical and equipment branch loads.

B. The later additions to the hospital have transfer switches for each branch of emergency power, but several of the panels are serving loads that should be on other branches for example:

· 1. Emergency panel ELL2A in electrical room 10 serves mixed loads.
·
· 2. Emergency panel LP1-A in room IS-3 serves mixed emergency loads.
·
· 3. Emergency panel 5A in 5th floor west machine room serves mixed loads.
·
· 4. Emergency panel 4A in the far west wing serves mixed loads.
·
· 5. Emergency panel EMLA in the front lobby serves mixed emergency loads.

Based on random observation during the survey walk through while accompanied by the Maintenance Electrician, (on the first day of the survey), and the Electrical Contractor, (on the second day of the survey), and the Plant Operations Secretary, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

A. The elevator cab lights were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32, and the elevator cab lighting disconnects in the elevator equipment rooms were not properly labeled in accordance with NFPA-70, Section 620-53.

B. The The original hospital patient rooms were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-18, and 517-19. This could effect all patients in this area if the transfer switch failed and no normal or emergency power was available at the bed locations.

C. The C-section rooms, the Operating rooms, the recovery rooms, the original ER rooms, and procedure rooms were not equipped with normal receptacles to meet the requirements of NFPA-70, Section 517-19.

D. Emergency receptacles were not labeled in all critical care areas such as the Cardiac Cath Lab, Phase 2 Recovery rooms, and the Eye Surgery rooms as required by NFPA-70, section 517-19.

Based on random observation during the survey walk through while accompanied by the Maintenenance Electrician and the Plant Operations Secretary, the surveyor found that the elevators did not meet all of the requirements of ANSI/ASME A17.3. This could affect any occupants of the facility using the elevator if proper safety equipment is not installed on each elevator.

Findings include:

A. The elevator machine rooms did not have a heat detector within 2' of each sprinkler head tied to a shunt trip as required by NFPA-72, Section 3-9.4, and ASME A17.1, Section 102.2(c)(3).

B. The elevators were not equipped with elevator recall initiated by smoke detectors in the elevator machine rooms, and lobbies in accordance with ANSI A17.1/A17.3.

Based on random observation during the survey walk through, accompanied by facility staff, the surveyor finds that a non conforming building is not separated from the health care occupancy by two hour rated construction as required by 19.1.1.4.1. This deficiency could affect the patients, staff, and visitors within the building in the event of a fire in the non conforming building.

Findings include:

A. At 9:20 AM on April 17, 2014, in the Basement, it was observed that the Loading Dock is not separated from areas of the Basement that are required by 19.1.6.1 to be protected construction. There is an unrated overhead door in the masonry wall that separates the Type I (332) Loading Dock area and the adjacent Type II (000) Autoclave Room Addition. 8.2.3.2.1

Based on observation during the survey walk-through while accompanied by the facility staff it was observed that components of the buildings designated construction type do not comply with, 19.1.6.2, and NFPA 220, 1999 Edition. This condition could affect individuals on the floor of fire incident from safely traveling the means of egress to the nearest exit.
Finding include:

A. Portions of the Hospital contain unprotected steel which does not comply with the minimum construction type requirements of 19.1.6.2. Example locations include:

1. 04/17/14 at 10:00 am 1st floor Solarium contains large unprotected steel beams. Location observed is the juncture of two corridors north of the Solarium. One leads from the E.D. The other from the Care Unit suite. Both have unprotected steel beams. These corridors meet at the North West corner outside of the Solarium.

2. 04/17/14 at 10:00am 1st floor Solarium contains unprotected steel tube columns (viewed above the suspended acoustical tile ceiling) location observed within the lower ceiling part of Solarium toward the skylight area.




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B. At 10:15 AM on April 16, 2014, on the First floor it was observed that combustible materials were used to build interior elements within the Solarium area, which does not comply with NFPA 220 1999 3-1. Locations include:

1. The decorative ceiling framing in the Cardiac Waiting Room was observed to be constructed of painted 2x lumber.

2. The ceiling over the alcove at the fire rated doors between the Cardiac Waiting Room and the corridor was observed to have plywood at the top. This assembly was indicated to be a part of a 2 hour separation assembly and a UL design was not provided.

Based on random observation during the survey walk through and staff interview, accompanied by facility staff, the surveyor finds that not all corridor wall finishes are in compliance with 10.2.3 and 19.3.3.2. During a fire/smoke emergency, this deficiency could affect all occupants from the exit stair and smoke compartment due to possible exposure to smoke producing materials.

Findings include:

A. At 9:33 AM on April 16, 2014, on the First floor, the walls in the corridor and stair lobby adjacent to the Business and Home Care Offices were observed to be covered with a material that was indicated to be jute. Documentation that this material has a Class A or Class B rating was not provided. 19.3.3.2

Based on random observation during the survey walk through, accompanied by facility staff, the surveyor finds that not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect any patients, staff, or visitors in the immediate area by permitting smoke to enter the egress corridor.

Findings include:

A. At 3:05 PM on April 15, 2014, on the First floor, the Men ' s Changing Room located near the Cat Scan Room, which is not constantly attended and which is observed to be open to the adjacent corridor, was observed to lack smoke detectors required by Subpart (c) of Exception 1 to 19.3.6.1.

B. At 3:00 PM on April 15, 2014, on the First floor, the Waiting Room and the Women ' s Waiting Room, located near the Cat Scan Room, which are not constantly attended and which were observed to be open to the adjacent corridor, were observed to lack smoke detectors required by Subpart (c) of Exception 2 to 19.3.6.1.

C. At 1:08 PM on April 16, 2014, in the Basement, it was observed that the corridor door at the Mechanical Room near the Wound Care Department is penetrated by a transfer grille, which is prohibited by 19.3.6.4.

D. At 1:15 PM on April 16, 2014, in the Basement, it was observed that the corridor walls at the Electrical Room and the Elevator Equipment Room near the Trash Chute Room are penetrated by transfer grilles, which is prohibited by 19.3.6.4

Based on observation during the survey walk-through while accompanied by facility staff, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients in the locations 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 occupied rooms.

Findings include:

A. At 9:25am on 04/16/14 2nd floor corridor doors to several suites have hardware which do not provide latching in order to comply with 19.3.6.3.2. Example locations include:

1. Assessment Suite (pair of doors to East corridor)

2. Phase II Recovery Suite (pair of doors to South corridor)

3. Phase I Recovery Suite (pair of doors to South corridor)

4. Phase I Recovery Suite (pair of doors to North corridor)



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B. At 2:57 PM on April 15, 2014, on the First floor, it was observed that the corridor door at the Fluoroscopy Room in the Radiology Department is not equipped with positive latching hardware as required by 19.3.6.3.2.

Based on random observation during the survey walk-though, accompanied by facility staff, the surveyor finds that not all shafts are enclosed with fire rated construction as required by 19.3.1.1. This deficiency could affect patients, staff and visitors in the event of a fire on a different floor.

Findings include:

A. At 2:55 PM on April 15, 2014, on the First floor, it was observed that an abandoned duct shaft in the X-Ray Film Developing Room is sealed at the bottom with sheet metal. It could not be determined if the required fire rating was intact above this material, and the room is not indicated to be of fire rated construction as required by 8.2.5.3

Based on observation during the survey walk-through, while accompanied by facility staff the means of egress to the public way is not apparent to comply with 19.2.10.1, 7.2.2.5.4 and 7.10.1.4. In the event of a fire/smoke condition any staff , patients and visitors present, may be unable to determine the most direct route to the level of exit discharge.

The finding is as follows:

A. On 04/15/14 at 11:30am in 4th floor Stair # 1 (North Stair) lacks any signage which will provide orientation and the level of exit discharge to comply with 7.2.2.5.4. This condition was observed in multiple exit stairs within the facility.

First Floor:

A. By direct observation the afternoon of 4/16/14 while in the company of the Manager of
Facilities the surveyor finds:
Above the ceiling by the cross corridor fire doors by the Respiratory Care Offices an installed fire damper in the smoke barrier above the corridor ceiling on the dietary side of the corridor. The above ceiling corridor space is used as a return air plenum for ventilation from the Respiratory Care Offices in non-compliance with NFPA 101, 19.3.7.3.

Based on observation during the survey walk-through,while accompanied by facility staff not all hazardous areas are separated from the remainder of the building to comply with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. 04/15/14 at 1:15 pm 1st floor Linen storage (located adjacent to Clean Linen within the corridor north of Dietary) contains an interior finish of wood paneling whch does not comply with 8.4.1.

B. 04/15/14 at 3:00PM 1st floor Clean Linen contains a corridor access door with a transfer grille which does not comply with 19.3.6.4.

C. 04/17/14 at 9:10am 1st floor Storage room adjacent to the exterior exit from the Dining Room. The room is not designed for storage to due to the following:

1. Louvers located in the South wall and entry door are open to the adjacent exterior sidewalk used for exit discharge from the Dining room and Stair # 2 (from Endo).

2. The room did not appear to be sprinkler protected.

3. The room did not appear to have a fire rated separation from the Dining room.

D. 04/17/14 at 9:00 am Basement Tunnels and Crawl spaces - There are underground spaces under the Hospital. Portions of these space are used as storage spaces. These spaces are not sprinklered and are not separated from other portions of the underground spaces (crawl spaces).


E. 04/16/14 at 9:00am 2nd floor Medgas Storage closet located in an Elevator Lobby east of Outpatient Surgery. This closet contains a pair of doors, one is not self closing.

Based on random observation during the survey walk-though, accompanied by facility staff, the surveyor finds that not all floors of the building have sufficient access to exits that terminate at an exterior exit discharge as required by 19.2.4.1. These deficiencies could affect patients, staff, and visitors on the cited floors in the event of an emergency evacuation.

Findings include:

A. In the morning of April 17, 2014, it was observed that more than 50% of the exit stairs that serve floors 3, 4, and 5 discharge on the level of exit discharge, which does not comply with 7.7.2. Locations observed include:

1. 5th floor - both exit stairs discharge internally.

2. 3rd and 4th floors - three of five exit stairs discharge internally.

Based on observation during the survey walk-through while accompanied by facility staff, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit discharge from the building.

Findings include:

A. At 1:15pm on 04/17/14 1st floor North exit stair from Surgery (discharge is interior North of Diatary) it was observed that conduit penetrations below the stair landing were not sealed to comply with NFPA 101-2000, 8.2.3.2.4.2.



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B. In the morning of April 15, 2014, on the Fourth floor, it was observed that the roofs of the exit stairs near the elevator (Stair 3) and at the north end of the north wing (Stair 1) are equipped with roof hatches that are intended to permit upward expansion of the stairs and so form the roof of the stair towers. The hatches do not maintain the stair enclosure as required by 7.1.3.2.1 as follows:

1. These hatches are not fire rated and do not have the 1 ½ hour protection required for roofs.

2. The hatches have not been maintained so are not weather or smoke tight. In the event of a fire smoke could be drawn into the stairs by the pressure differential created by the gaps in the hatches

3. Rain could enter the stair tower through the gaps in the hatch assembly and compromise the walking surfaces below.

Based on random observation during the survey walk-though, accompanied by facility staff, the surveyor finds that exit access is not arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the building.

Findings include:

A. At 1:35 PM on April 15, 2014, on the Second floor, the corridor that connects the Surgery Department with the ICU Suite has exit signage that directs the path of egress from the corridor into the ICU suite, which is an intervening room. Without a means of egress at the west end of this corridor a dead end of approximately 80 feet is created. 19.2.5.9

B. At 9:00 AM on April 16, 2014, on the First floor, it was observed that the corridor door at IS 2 in the Open Heart Department is equipped with a deadbolt lock that requires a key to operate from both sides. 19.2.2.2.4

C. At 9:20 AM on April 16, 2014, on the First floor, it was observed that a padlock is used to secure the door of the Gift Shop at the Lobby area, which does not comply with 39.2.2.2.1. There is no other path of egress from the Gift Shop that does not pass through a storage room, which does not comply with 7.5.2.1.

D. At 8:50 AM on April 17, 2014, in the Basement, it was observed that a Pharmacy corridor door marked with exit signage is locked on the egress side with an electric strike that is opened from a remote switch, and so cannot be opened readily without special knowledge. 7.2.1.5.1

E. At 10:57 AM on April 16, 2014, in the Basement, it was observed that the door in the horizontal exit between the main Hospital and the adjacent Professional Building is equipped with hardware that can be locked from the Professional Building side against Hospital egress. 19.2.2.2.4

F. At 11:13 AM on April 16, 2014, in the Basement, it was observed that the corridor door at the Mechanical Room located near the Hyperbarics Room is equipped with a magnetic lock. It could not be determined if it is functional or under which conditions it would be locked or unlocked. 19.2.2.2.4

Based on random observation during the survey walk-through while accompanied by the Facility Staff, not all designated suites comply with 19.2.5 concerning the remotely located exit access doors. This condition may affect patients, staff and visitors during a fire emergency by increasing the amount of time and travel distance required to reach an exit access corridor.

Finding includes:

A. On 04/16/14 at 10:10am 2nd floor, Assessment Suite; exit access to a corridor is not indicated from the East pair of doors. This condition does not comply with 19.2.5.3 for two remotely located means of egress.

Based on random observation during the survey walk-through while accompanied by facility representatives, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all patients, visitors and staff within the areas of the fire compartment, as well as any persons in the adjacent compartment, because failure to construct and maintain fire resistive assemblies could allow fire and smoke to pass from one compartment into adjacent fire/smoke compartments.

Findings include:

A. 04/16/14 at 1:45PM 1st floor adjacent to Diatary contains a pair of cross corridor doors within a designated 2 hour barrier wall. The wall (above the pair of doors) contains a duct penetration which lacks an access panel for a required fire damper.

B. 04/15/14 at 2:30pm 2nd floor "center" mechanical room adjacent to Surgical Waiting contains an unprotected steel beam as part of a designated 2-hour enclosure. The beam is located within the barrier wall behind the roof hatch ladder.

Based on random observation during the survey walk-through while accompanied by Facility Staff, battery powered emergency illumination is not provided to comply with 19.2.9.1, 7.9 and NFPA 99-1999, 3-3.2.1.2 for locations of anesthetized patients. This deficiency could affect any patients, and staff due to any failure with normal lighting which could prevent them from safely exiting the building under fire conditions.

Findings include:

A. During the survey walk through, battery powered emergency lighting was not provided to comply with NFPA 99-1999, 3-3.2.1.2(a)5(e). Example locations as follows:

1. 04/16/14 at 1:12pm 2nd floor C-Section Operating room. During an interview held with the Nurse Manager for the OB Dept. it was determined that none of the C-Section Rooms contained battery powered emergency lighting.

2. 04/16/14 at 1:15pm 2nd floor Endoscopy rooms

3. 04/16/14 at 1:18pm 2nd floor "Eye" Operating rooms

4. 04/16/14 at 1:25pm 2nd floor Phase I Recovery

5. 04/16/14 at 1:30pm 2nd floor Phase II Recovery



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6. 04/16/14 at 8:50am 1st floor Cardiac Cath Lab 3 was observed to not contain battery powered emergency lighting.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress to comply with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit during a fire or smoke event.

Findings include:

A. Exit signs are not provided to identify the 2nd means of egress from corridors to comply with 19.2.5.9. Locations noted include the following:

1. On 04/16/14 at 2:45pm 2nd floor corridor East of Assessment Suite was observed to lack a means to identify both egress paths in order to comply with 18.2.5.9. a single exit sign was observed leading to the Endo Corridor.

Based on random observation during the survey walk through while accompanied by the Electrical Contractor and the Plant Operations Secretary, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA-72. This could affect all occupants of the building if the fire alarm system did not operate properly during a fire emergency.

Findings include:

A. The fifth floor west machine room did not have a smoke detector near the fire alarm panel to meet the requirements of NFPA-72, Section 1-5.6.

B. Panel ELL1A in wiring closet #9 had a circuit breaker serving a fire alarm panel that was not marked in red and was not equipped with a circuit breaker lock to meet the requirements of NFPA-72, Section 1-5.2.5.2.



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C. 04/16/14 during testing of the fire alarm system, the visual and audible notification devices did not operate in a manner to give warning in accordance with NFPA 72 4-4. Locations and conditions include:

1. Second floor Endo suite, surveyor was unable to hear any audible devices anywhere within this suite.

2. Second floor assessment, surveyor was unable to hear an audible device within the area.

3. Second floor Phasr I and Phase II Recovery lacks a visual notification device.



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4. Fourth floor Nurses' Station, it was observed that the audible signal was not readily discernable over the ambient noise.

D. At 10:57 AM on April 16, 2014, in the Basement, it was observed that the horizontal exit between the main Hospital and the adjacent Professional Building is not provided with a fire alarm pull station within 5 feet of the door as required by 9.6.2.3 and NFPA 72 1999 2-8.2.2.

Based on random observation during the survey walk, while accompanied by facility staff, failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors. The installation does not comply with NFPA 13 1999

Basement:

By direct observation while in the company of the Manager of Facility's the surveyor finds the:

A. Morning of 4/16/14, the Electrical B3 is not provided with sprinkler protection and does not qualify for the exception for elimination of sprinkler protection as listed in NFPA 13, 1999, 5-13.11. The room is not dedicated to electrical equipment and contains building systems pneumatic control compressors.

B. Afternoon of 4/16/14, the Electrical Room B5 is not provide with sprinkler protection and does not qualify for the exception for elimination of sprinkler protection as listed in NFPA 13, 1999, 5-13.11. The room enclosure lacks sealing of pipe/conduit penetrations and rated doors in the barrier separating the electrical room and the room containing the batteries for the UPS and various pipe supplies.

C. Afternoon of 4/16/14, the access through Storage B6 to the Crawl Space is being used for storage of plumbing supplies. This Crawl Space is not provided with sprinkler protection.

D. Morning of 4/17/14, the hydraulic equipment room and associated shaft for Elevators 20 & 21 are not provided with sprinkler protection as required by NFPA 13, 1999, 5-13.6.





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E. 04/16/14 2:15pm 2nd floor "Center" Mechanical room located between Stair # 3 and Surgery Waiting contained a sprinkler pipe improperly anchored to the bottom of a duct. The pipe was observed to be shaking due to vibration from the duct.


F. 04/16/14 at 9:10am 2nd floor Assessment suite contains 3 Linen Closets (within the main aisle) which lack sprinkler protection

G. 04/15/14 at 10am 4th floor closet located ina corridor alcove leading to Nurse Manager office contains stored items including a blue duffel bag along with multiple shelves with plastic wrapped items. This closet lacks sprinkler protection.

H. 04/16/14 at 1:45pm 2nd floor corridor closet adjacent to Surgery Break room and across the corridor from Phase I Recovery suite contains numerous combustible items and lacks sprinkler protection.



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I. At 9:05 AM on April 17, 2014, in the Basement, it was observed that the morgue cooler lacks sprinkler protection as required by NFPA 13 1999 5-1.1(1).

J. At 9:25 AM on April 17, 2014, in the Basement, it was observed that the Boiler Operator's Office located in the Autoclave Room addition lacks sprinkler protection as required by NFPA 13 1999 5-1.1(1)

Based upon random observation during the survey walk through while accompanied by Facility Staff the surveyor finds that HVAC systems do not comply with NFPA 90A 1999 and/or ASHRAE.

Findings include:

A. 04/16/14 at 1:15pm 2nd floor "Center" mechanical room adjacent to Surgery Waiting room contains a fire damper and/or combination damper that is not installed within the plane of the fire barrier. A damper is installed well beyond the plane of the 2-hour fire/smoke barrier. A built out angled gypsum board box is constructed out from the barrier wall. A duct penetrates it having an access panel and damper installation at the face of the angled box. This installation does not comply with the damper manufacturer's requirements and/or NFPA 90A.

B. 04/16/14 at 1:15pm 2nd floor "Center" mechanical room adjacent to Surgery Waiting and a corridor. The 2-hour barrier above the corridor entry door contains duct penetrations. The ducts lack damper installations and access panels to comply with NFPA 90A.

1. The same barrier is incomplete above the duct penetrations with only sheet metal forming the barrier from the top of the duct to the underside of the deck above. Therefore the ducts are improperly supported which does not comply with NFPA 90A 2-3.1.4

2. The same barrier contains a duct penetration with a dampered transfer grille which does not comply with 19.3.6.4. The duct penetration is located in the area above the entry door.

C. 04/15/14 at 1:30pm 2nd floor maintenance staff corridor (north of Surgery) access provided from 1st floor Mechanical stair adjacent to Respratory Therapy and north Diatary corridor. An overhead duct penetrates the designated 2-hour barrier wall at the second floor staff corridor which lacks a damper and access panel.

Based on random observation during the survey walk through, while accompanied by facility staff, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. This deficient practice may compromise the prompt care and movement of occupants from the 4th, 3rd, and 2nd floor North Stair along with persons within Diatary during a fire/smoke emergency.

Findings include:

A. Means of egress corridors are not maintained free of obstructions to comply with 7.1.10. Locations/conditions observed include:

1. 04/16/14 at 1:50pm 1st floor exit access corridor North of Diatary is utilized for storage of linen carts. The amount of carts stationed within the corridor provide an obstruction for the means of egress from Stair #1 (from Surgery).

2. 04/16/14 at 1:50pm 1st floor exit access corridor North of Diatary is utilized for storage of plastic cartons which are stacked up at the location where the corridor width diminishes. The cartons stationed within the corridor provide an obstruction with in the means of egress.

3. 04/16/14 at 2:30pm 1st floor exit access corridor adjacent to Diatary Offices is utilized for storage of linen carts. The carts are stationed within the corridor reduce the required width of the corridor and block access to a pair of cross corridor doors within the means of egress.

Based on random observation during the survey walk through while accompanied by the Maintenance Electrician, (on the first day of the survey), and the Electrical Contractor, (on the second day of the survey), and the Plant Operations Secretary, the surveyor found that the emergency electrical system installation did not meet all requirements of NFPA-70, NFPA-99, and NFPA-110. This could affect any occupant of the facility if a transfer switch fails and all branches of emergency power and normal power are lost are lost.

Findings include:

A. It was observed that the original hospital was not equipped with a separate transfer switch for each branch of emergency power as required by NFPA-70, Section 517-30.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the
survey walk-through, the provider shall institute the 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 while accompanied by the Electrical Contractor and the Plant Operations Secretary, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. Emergency power for the original hospital is not separated into three branches as required by NFPA-70, Section 517-30 through 517-35. All 120-208 volt load is served from a single transfer switch and it was observed that the panels served from this transfer switch were a mixture of life safety, critical and equipment branch loads.

B. The later additions to the hospital have transfer switches for each branch of emergency power, but several of the panels are serving loads that should be on other branches for example:

· 1. Emergency panel ELL2A in electrical room 10 serves mixed loads.
·
· 2. Emergency panel LP1-A in room IS-3 serves mixed emergency loads.
·
· 3. Emergency panel 5A in 5th floor west machine room serves mixed loads.
·
· 4. Emergency panel 4A in the far west wing serves mixed loads.
·
· 5. Emergency panel EMLA in the front lobby serves mixed emergency loads.

Based on random observation during the survey walk through while accompanied by the Maintenance Electrician, (on the first day of the survey), and the Electrical Contractor, (on the second day of the survey), and the Plant Operations Secretary, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

A. The elevator cab lights were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32, and the elevator cab lighting disconnects in the elevator equipment rooms were not properly labeled in accordance with NFPA-70, Section 620-53.

B. The The original hospital patient rooms were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-18, and 517-19. This could effect all patients in this area if the transfer switch failed and no normal or emergency power was available at the bed locations.

C. The C-section rooms, the Operating rooms, the recovery rooms, the original ER rooms, and procedure rooms were not equipped with normal receptacles to meet the requirements of NFPA-70, Section 517-19.

D. Emergency receptacles were not labeled in all critical care areas such as the Cardiac Cath Lab, Phase 2 Recovery rooms, and the Eye Surgery rooms as required by NFPA-70, section 517-19.

Based on random observation during the survey walk through while accompanied by the Maintenenance Electrician and the Plant Operations Secretary, the surveyor found that the elevators did not meet all of the requirements of ANSI/ASME A17.3. This could affect any occupants of the facility using the elevator if proper safety equipment is not installed on each elevator.

Findings include:

A. The elevator machine rooms did not have a heat detector within 2' of each sprinkler head tied to a shunt trip as required by NFPA-72, Section 3-9.4, and ASME A17.1, Section 102.2(c)(3).

B. The elevators were not equipped with elevator recall initiated by smoke detectors in the elevator machine rooms, and lobbies in accordance with ANSI A17.1/A17.3.