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A) Due to the amount of additions and the various construction types for this building, the overall healthcare building cannot be determined to comply with 19.1.6.2 and NFPA 220 for a partially sprinklered building. Example location:

1). 3rd Floor of South addition - observed from "2 South" interstitial space, Surveyor questioned the fire resistant rating for the metal deck/concrete floor slab for the 3rd floor level which would constitute a fire resistant rating and maintain the buildings construction type.
Surveyor observed the metal deck for the third floor above, while in 2 South. 2 South is a large interstitial space and the provider representative stated that they consider it part of the 1st Floor ( ceiling cavity).
Not all light fixtures are "tented" to maintain a fire resistant floor/ceiling assembly. Therefore, the surveyor questions the fire resistance rating for the floor deck above (Provider refers to as 3rd Floor).
The provider showed the surveyor floor/ceiling assembly details for fire resistant installations throughout the building. However, the details appeared to exclude the ceiling part of the floor/ceiling assembly for the South addition. The Provider stated that the interstitial space is then part of the first floor.
Therefore, any penetration through the 3rd floor slab would need to be properly dampered, sealed etc. Surveyor did not see evidence of this.





2). Steel beam was observed which was not fully fire protected to comply with NFPA 220. Location observed: Ground floor exit stair for the basement. Steel beam above the ceiling lacks fire proofing.

A). Based on random observation during the survey walk through the surveyor noted numerous designated suites which did not appear to comply with 19.2.5. Example location listed:

1). 1st Floor, ICU suite (approx 6,555 s.f.) does not comply with 19.2.5.6 for the maximum allowable square footage for a sleeping room suite.


B). 1st Floor Surgery suite (approx 9,829s.f.) contains an exterior exit having a travel distance within the suite which appears to exceed 100 feet and does not comply with 19.2.5.8. The exit located on the East side of the suite also does not have a travel distance to the exit from the farthest room(s) in the O.R. suite which can be achieved within 100 feet.


C). 1st Floor Surgery suite (approx 9,829s.f.) contains two other designated exits (one through the Recovery Suite and one through three pairs of cross corridor doors to an exit access corridor. Both of these designated exits have a travel distance which exceeds the number of allowable intervening rooms in order to comply with 19.2.5.8.

A) Based on random observation (and staff interview) during the survey walk-through, not all components of the facility's fire alarm system are installed and maintained in accordance with NFPA 72 1999.

1). During the building walk-through and staff interview held at the fire alarm control panel it was confirmed the panel was not labeled with the electric panel and circuit serving the panel as required by NFPA 72 1.5.2.5.2.

B). During the survey walk-through a fire alarm pull station was observed in the maintenance corridor on the first floor not with-in 5' of an exit doorway as required by NFPA 72 2-8.2.2.

C). During the building walk-through and staff interview held at the fire alarm control panel it was confirmed the electric panel serving the fire alarm control panel was connected to the Critical Branch of the emergency electric system and not the Life Safety Branch as required by NFPA 72 1-5.2.5.2.

D). The circuit breaker serving the fire alarm control panel was observed to not be identified in red as required by NFPA 72 1-5.2.5.2.

E). The circuit breaker serving the fire alarm control panel was observed without a mechanical lock as required by NFPA 72 1-5.2.5.2.

A) Based on random observation (and staff interview) during the survey walk-through, not all portions of the facility's heating and air conditioning systems are installed in accordance with NFPA 90A 1999.


1). In the north mechanical room by stair C a duct was observed to have a fire damper install in a duct transition passing through the south wall of the equipment room as prohibited by NFPA 90A 2-3.2.1.4.

2). The equipment room east of stair C was observed to have a duct passing through the east wall without a fire damper installed as required by NFPA 90A 3-3.1.1.

A) Based on random observation (and staff interview) during the survey walk-through, not all linen and trash chutes are installed in accordance with NFPA 82 1999.

1). During the survey walk-through a linen chute door in the third floor corridor was not enclosed with construction of the same fire resistance rating as the chute as required by NFPA 82 3-2.3.

A) Based upon random observation, the surveyor finds that exit access corridor areas are obstructed in width by equipment and furniture in the corridor. In some cases (see K042) the surveyor is not able to confirm an area is part of a suite instead of a required exit access corridor:

1) The 1st Floor Corridor within Endoscopy (close to Exam Room # 1) was obstructed by carts, wheelchairs and gurneys. Surveyor observed no staff or patients in the corridor or other areas.

2) Corrected 05/28/10.

3) Example location 2nd Floor The corridor was obstructed by carts, and workstation on wheels which were being charged from corridor outlets. Surveyor observed this condition on each Med/Surg floor.

A). During the fire alarm testing, the elevator lobby smoke detector was activated on the ground floor by stair B and the fireman's recall sequence was not initiated as required by NFPA 72 3-9.3.2.