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A) Based upon personnel interview and random observation during all three days of the survey, the surveyors find that vertical openings are not enclosure in accordance 19.3.1.1 and NFPA 90A:

1) Corrected 03/18/15

2) The surveyors find from random observation and review of plans, that there are concrete block shaft enclosures at the west side of the West stair and at the east side of the East Stair on the 2nd, 3rd and 4th Floors. Duct penetrations through the floor and/or into these shaft enclosures lack fire dampers in accordance with NFPA 90A. Access to investigate this condition was limited by ceiling conditions and/or due to semi-sterile environments with no access on some floors.

04/10/13 - A PoC was not provided for the above item. No correction date was provided. Both the plan of correction lack specifics for the above locations. The PoC does not clearly identify what is proposed for each floor and the project plans for Project 9561 do not accurately identify the shaft enclosures at duct penetrations at each floor. Based on observation on 4/10/13, the surveyor observed that two fire dampers are missing above the 4th Floor ceiling at each end of the building (at the locations cited).

B. Corrected 03/18/15


20224


Based on random observation during the survey walk through on the afternoon of 9/20/2011, the surveyor accompanied by the Director of Facilities finds that vertical openings are not enclosed comply with 8.2.5.3. Unenclosed shafts may affect patient care areas on several floors and smoke compartments, preventing the safe movement of patients, visitors and staff during a fire emergency.

Finding as follows:

3. 2nd floor, corridor # C-22 adjacent to Stair # 3 and to Cardinal Sleep Lab, several bathroom exhaust ducts extend up to the floor(s) above within a shaft that is open to this corridor.

B). On the morning of 09/19/2011, duct penetrations through the walls of 2 hour fire rated ventilation shafts were observed which lack fire dampers to comply with 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1. Locations observed include:

2. Corrected 08/19/14.

3. Corrected 03/08/12