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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 38.3.2.1.

Findings include:

A. Soiled Utility Room, door is not self-closing as required for a hazardous area.

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.

Findings include:

A. Corrected 10/28/10.



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B. Fire rated exit passageways were observed at which utilities unrelated to the enclosure (data cables) have been installed as prohibited by 7.1.3.2.1(e). Locations observed include (all First Floor Building B):

1. Exit Passageway for Exit Stair 4.

2. Exit Passageway for Exit Stair 7.

C. Doors to normally unoccupied rooms were observed in fire rated exit enclosures as prohibited by 7.1.3.2.1(d). Locations observed include:

1. Building A Lower Level landing of Exit Stair 3, door to Store Room TB063.

2. Building B First Floor Exit Passageway for Exit Stair 4, door to Store Room T1029.

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.

Findings include:

A. The 4th floor Mechanical room above Surgery has a 4" curb at the threshold of the west stair door and the adjacent elevator machine room door in non-compliance with 7.2.1.3.

B. Corrected 10/28/10.

C. The 2nd floor Medical Library west exit to the stair has a step at the door in non-compliance with 7.2.1.3.

D. The 1st floor Emergency Dept. Lobby entrance has a revolving door marked as an exit. Conditions observed include:

1. The revolving door does not have an adjacent complying swinging door within a minimum 20' to comply with 7.2.1.10.1(e) Exception No. 2.

2. It was not confirmed that the revolving door complies with 7.2.1.10.2 regarding this door being utilized as a component of the required means of egress.

E. Corrected 10/28/10.

F. Corrected 10/28/10.

G. Corected 10/28/10.



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H. Corrected 10/28/20.

I. The Building B Sub-Basement was observed was observed to lack at least 1 exit stair which discharges directly to the exterior of the building as required by 7.7.2.

J. Corrected 10/28/10.

K. Corrected 10/28/10.

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 39.2.10.1 and 7.10.

Findings include:

A. Exit corridor is approximately 214' in length. The corridor only contains two exit signs, one at each end of the corridor. The distance between these exit signs exceeds the 100' maximum allowed 7.10.1.4.

Based on random observation during the survey walk through, not al portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13, 1999.

Findings include:

A. Rooms and spaces were observed at which sprinkler layout was observed to not provide complete coverage as specified by NFPA 13, 1999. Locations observed include:

1. Lobby, the sprinklers are locate under the soffits at the perimeter of the room. The center of the room contains a raised ceiling and a large shelving unit which is not provided with any sprinkler coverage.

Based on random observation during the survey walk through, not al portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13, 1999.
Findings include:

A Rooms and spaces were observed at which sprinkler escutcheon rings were observed to be missing as prohibited by NFPA 13, 1999. Locations observed include:

1. Biohazard Room.

B. Rooms and spaces were observed at which ceiling tile were observed to be missing or contained penetrations, which compromises sprinkler coverage as prohibited by NFPA 13, 1999, 5-6.4.1.1 and 5-7.4.1.1. Locations observed include:

1. Storage room behind the nursing desk, the ceiling tiles were over cut creating a large gap around the wire bundle penetration.

Based on random observation during the survey walk-through and document review, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A.

Findings include:

A. A series of shafts housing toilet exhaust ducts were observed, throughout Building B, which do not carry a minimum 2 hour fire resistance rating required by NFPA 90A 1999 3-3.4.1. Surveyor 14290 notes that, according to the provider's Life Safety Drawings, there appear to be 18 such shafts and that they appear to communicate with the Ninth through Second Floors.

B. Corrected 10/28/10.

C. Corrected 10/28/10.



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By direct observation the facility failed to provide:

A. Corrected 10/28/10.

B. Corrected 10/28/10.

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 or other emergency in accordance with 18.2.3.3 and 7.1.10.2.1. Findings include:

A. Corrected 10/28/10.

B. Corrected 10/28/10.

C. Corrected 10/28/10.



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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 or other emergency in accordance with 19.2.3.3.

Findings include:

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

1. The 3rd floor Surgery Dept. is a combination of suites and exit access corridors. The exit access corridors are utilized for storage of equipment/stretchers/carts used in the ORs. The full width of the corridors are not available for full instant use. Although alcove spaces are provided, the amount of equipment stationed open to the corridors exceeds the available space of the alcoves.

NEW 10/28/10: Surveyor 14290 observed, carts, equipment, and gurneys being stored in the main Corridor serving the Operating Rooms as prohibited by 19.2.3.3. and 7.1.10.2.1. The provider's Life Safety Plans indicate that the Corridor in which the materials were observed is an exit access corridor.



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B. Corrected 10/28/10.

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. Corrected 10/28/10.

B. Corrected 10/28/10.

C. Corrected 120/28/10.



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D. 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, it can not be determined how the hyperbaric center meets with NFPA 99, based on the following observations:

A. NFPA 99, 19-2.1.1.2 manufacturers specifications for hyperbaric chambers indicate that the units are placed on casters for mobility in allowing the user to easily reposition or relocate the chamber as required for maintenance. However, it is basically a stationary unit since it must be supplied with oxygen and electrical connections from within the room. If this is the situation on the two chambers, then the room would be required to meet with 19-2.1.1 and a 2 hour room enclosure would be required.

B. The construction Type 2 (000), will not provide a 2 hour rated floor separation.

C. This room contains a 45 minute rated door and the walls are not rated to meet the 2 hour rated requirement.