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A) Based on random observation during the survey walk-through, the surveyor finds that not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. Portions of steel beams were observed with missing fire proofing. Locations observed include:

1) Corrected 10/05/10

2) Basement Level

a) Corrected 10/05/10
b) Corrected 10/05/10
c) Corrected 11/08/11






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Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2.

Findings include:

C. 1st floor, ER ambulance canopy contains metal columns that support this roofing system and are not enclosed or provided with fire proofing material.

11/08/11: A small portion of this canopy remains unprotected. Also, a portion of the E D east Foyer with the revolving door has a beam that has missing fire proofing. Access above the ceiling in this area was obstructed by insulation above the ceiling.





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D. Corrected 06/02/11

A) Corrected 06/03/11



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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1.

Findings include:

B. Modified 11/08/11: Staff work areas which are open to the corridors were observed which are not provided with smoke detectors required by Exception 1. [subpart(c)] to 19.3.6.1.
Second Floor::

5. Treatment Unit Work Areas as part of Corridor 2200. The PoC for this item does not appear to be accurate; the corridor in question appears to serve patient treatment rooms. How does the corridor comply with the above?

It is not clear how the above area complies with 19.3.6.1 or the rules for suites. If this area is not a suite, it lacks smoke detection throughout all areas that are open to the corridor. However, it appears to be a suite. K017 will clear when the PoC identifies this space as a suite. See also K042

A) (New 06/03/11) Based on random observation, the surveyor finds that fire doors, smoke doors and/or fire shutters are not tied to local smoke detection and/or do not close upon activation of smoke detections in accordance with 19.2.2.2.6:

1) Corrected 11/08/11

2) Corrected 11/08/11

3) Deleted 11/08/11

4) Blood Bank Lab 3150 is designated with a one hour fire rated enclosure; based upon testing on 6/03/11 and 11/08/11, the fire shutter did not close completely.

5) Corrected 11/08/11

6) (New 11/08/11): Clean Room 756W. The self closing door to this hazardous area room hangs up on the floor.






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A. Corrected 06/02/11

A) From random observation, the surveyors find that hazardous areas are not enclosed in accordance with 19.3.2.1, and/or 8.4.1.1 and hazardous areas are not separated from other use areas.

1) The Basement Level (Concourse) has a 12' wide, Main Corridor that extends east and west the length of the building. The Basement Level lacks a separate holding area for soiled linen, soiled waste and bio-hazard waste. The 12' wide Basement Corridor is used to stage and hold equipment, supplies, and furniture, along with soiled linen carts, waste carts and bio-hazard waste. The west end of the corridor by the end of the day is filled with soiled materials carts to the point that access to the west stair (Stair # 2) becomes blocked.

a) The 12' wide corridor is a required
means of egress for multiple office and
service areas at this level (but not for
health care). The means of egress for
such areas are prohibited from exit
through this area of higher hazard as
prohibited by 39.3.2.1. and 8.4.1.1.

11/08/11 - the surveyor observed that provider is not following the PoC and written policy for the above area. Pallets supplies were observed in the corridor, obstructing a portion of the 8'-0" width. An unused wood pallet was left in the corridor and a significant number of wheeled waste cards for shredded paper were found in this corridor, obstructing the corridor down to about 5'-0" in width.

2) Corrected 06/03/11

3) (New 11/08/11): The 3rd Floor East Surgical Suite is an oversized suite (see K042). The north corridor and the back corridor (near the east stair) is continuously lined with stored equipment, materials, supplies, beds, etc. The total area of combustible storage is well in excess of 100 square feet in area and does not comply with 19.3.2.1. Some of the material is covered with sheets and most of the items observed in the aisles of this suite belong in storage or holding rooms.




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B. Hazardous areas covered by a sprinkler system were observed at which doors are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include:

2. Fourth Floor Clean Storage Room 4261 -
the item was corrected 06/02/11,
however the door was wedged open
This was uncorrected on 11/07/11; the
provider lack effective means to prevent
re-occurrence.

A. Corrected 06/02/11



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B. (Modified 06/03/11) Six of seven required exit stairs do not comply with 7.2.1.5.2. exception # 1. Surveyors note: 19.2.2.8 cannot be used under exception # 2 except on a stair by stair and floor by floor basis. 19.2.2.8 cannot be used in this facility to lock ever door in a stair against re-entry except under limited conditions that are identified under exception # 1. Further, signage was was not found within the exit stairs which clarifies to building occupants on which levels re-entry is not permitted and on which levels re-entry is permitted. This condition was observed at all Exit Stair as identified below (does not apply to Stair # 4 which has no locks against re-entry).

1. Exit Stair 1.

2. Exit Stair 2.

3. Exit Stair 3.

4. Exit Stair 5.

5. Exit Stair 6.

6. Exit Stair 7.

C. Exit stairs were observed that are not provided with signage within the enclosure that identifies the story, the top and bottom terminus, and the stair enclosure identification in accordance with 7.2.2.5.4. Such signage shall be visible within the stair enclosure whether the stair door is open or closed. Locations observed include:

1. Corrected 06/03/11
2. Corrected 06/03/11
3. Corrected 06/03/11

4. Exit Stair 4.

5. Corrected 06/03/11
6. Corrected 06/03/11
7. Corrected 06/03/11

06/03/11: Stair # 4 was not cleared becuase the terminus was not properly identified; the stair provides roof access but the stair identificatoin signage does not indicate such.

A) (New 11/08/11): Treatment Unit Work Areas as part of Corridor 2200. This area appears to be a suite and is identified on Life Safety Plans as a Suite. The adjacent suite is vacant and under construction.

1) The suite does not appear to have two remote exit paths from the suite. The corridor door to the south does not swing in the direction of exit travel.

2) The path to the northwest requires travel into an adjacent suite (permitted) to get to a stair. The foyer in front of the stair is used as a storage holding space (not permitted - does not comply with 19.3.2.1.)

3) A door top the adjacent suite was wedged open.

4) The file storage room at the north end of this suite that is a hazardous area. The door closer on this door to this room has been removed; the door no longer complies with 19.3.2.1.





12798


Based on random observation during the walk-through, not all designated suites are provided with exits in accordance with 19.2.5.

B. (Modified 11/08/11) 3rd floor, the designated OR Suites exceed 10,000 square feet as prohibited by 19.2.5.7. Based on the PoC and Life Safety Plans, the suite has broken up into multiple smaller O R Suites.

1. The East Suite still exceeds 10,000 Square Feet (Suite 3-2 - 11,220 SF)

2. See K042 - corridors are obstructed

3. The Surgicenter Suite is to large to have only one exit path out of it. A 2nd remote exit path is either not available or has too many intervening rooms. The surveyor also notes that the exit access corridor to the east is directed into the suite via exit signs in the corridor. This area, corridors and suites lack coordination with the PoC and FSES.

C. (Modified 11/08/11) The 1st floor, the designated Emergency Department Suite is identified as 14,398 square feet in area and exceeds the 10,000 SF limit as prohibited by 19.2.5.7.

A) Corrected 6/03/11


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B. During a series of interviews held throughout the survey walk-through between February 22 and 25, 2010, the provider's staff was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 19.7.1.1. Further, during the survey walk-through, it was determined that existing records of such components were inaccurate for the reasons listed herein. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include, but are not necessarily limited to:

7. The limits and areas (in square feet) of all suites. Surveyor 14290 notes that:

a. Numerous portions of the building
appear to constitute suites as defined by
19.2.5, but are not shown on the
provided drawings as such.

1) Corrected 06/03/11

2) Second Floor: 6/03/11: the areas
referenced below are not located
within the suites identified in the
POC.
a) Corrected 11/08/11

b) Corrected 11/08/11

c) Corrected 11/08/11

d) Pediatric Heart Unit which
includes Office 2105. 11/08/11
this unit appears to have patient
treatment rooms within; it is
not identified on plans as a suite

e) Corrected 11/08/11

f) Corrected 11/08/11

b. Suites are not accurately shown
(also refer K-042).
Locations observed include:

1) Corrected 06/02/11

2) Third Floor Surgical
Department Suites.

3) Deleted - see K042

9. Deleted 11/07/11

C) (Unresolved 06/03/11): The plan provided for this survey continue to identify corridors inside designated suites. This creates a conflict between the rules for exit access corridors and the rules for suites. In such cases the rules for corridors will be suited and some of the suites will not comply.

The above item was not corrected in accordance with the last submitted POC.

A) Corrected 06/03/11

1. The existing fire alarm system is not installed and maintained in accordance with NFPA 101, NFPA 25 and NFPA 72:

2. Basement Level C 900: These is a smoke detector in this space that is mounted four feet below the deck above.

3) Corrected 11/08/11 - based upon written policy and testing.





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B. Corrected 06/03/11

A) Based upon random observation the surveyors find that sprinklered systems are not installed and maintained in accordance with NFPA 13:

1) Electrical Rooms typically are not sprinklered and instead use an exception under NFPA 13 that requires a two hour fire rated enclosures for each unsprinklered electrical room. A number of electrical rooms do not comply with the exception under NFPA 13:
a) Corrected 10/05/10
b) Corrected 11/07/11
2) Sprinkler heads are not installed in accordance with NFPA 13:
a) Corrected 11/07/11
b) Corrected 10/05/10
c) Corrected 11/07/11
d) Corrected 11/07/11

e) New 11/07/11: 9th Floor Mechanical
Room

Areas under ducts where the sprinkler
head is at the duct level but is not under
the duct.

Storage near Stair # 9 is closer than 18"
below the sprinkler heads.

SE - Caged area for refrigeration
engineers. The roof of this cage obstruct
the sprinkler protection

f) (New 11/08/11): Sprinkler closet 536W
lacks sprinkler protection

3) Sprinkler protection (and any fire alarm detection devices) are compromised by missing of ceiling tiles in lay-in ceilings. Locations include but are not limited to:

a) Basement Level

Ë446 - Linen Holding Room

Corrected 11/07/11
Corrected 11/07/11
Corrected 10/05/10
Corrected 10/05/10
4) Corrected 11/08/11 per narrative
5) Corrected 11/08/11 per narrative
6) Corrected 11/07/11




12798

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

C. Rooms or spaces were observed at which ceiling tiles or surfaces were observed to be missing or damaged compromising sprinkler coverage as prohibited by NFPA 13, 1999 5-6.4.1.1. Locations observed include:

7. 1st floor, Storage (1133) off of main
lobby. On 6/03/11, the surveyor
observed that the sprinkler head was
obstructed by storage closer than 18"
below the head.

Uncorrected 11/08/11

E. Sprinkler heads were observed that are are not being maintained in accordance with NFPA 25, 1998. Conditions observed include:

1. Corrected 06/02/11
2. Corrected 11/07/11.

F. Sprinklers were not installed in the following locations as required for a fully sprinkled facility.

1. Corrected 06/02/11
2. Corrected 06/02/11
3. Corrected 11/07/11



14290


G. Patient Sleeping Room Wardrobes were observed that are not covered by the automatic sprinkler system as required by NFPA 13 1999 5-1.1(1). Locations observed include:

1. Corrected 11/07/11
2. Corrected 06/02/11

H. Corrected 11/07/11
I. Corrected 11/07/11
J. Corrected 06/02/11




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K. Modified 06/02/11: The low sprinkler head installed in front of Panel MCC, P-3A - ATS-7 is not installed in accordance with NFPA 13.

11/07/11 - the above item was uncorrected; at least two sprinkler heads are too low.

A) Based upon random observation and document review, the surveyors find that fire dampers and/or fire/smoke dampers are not installed and maintained in accordance with NFPA 90A.

1) According to the provider and based upon documentation, fire dampers were tested, cleaned and maintained in 2007 for the 949 Building (Main Hospital). The documentation identifies dampers that could not be accessed, dampers that need cleaning or replacement, dampers that are broken etc.

11/08/11 - based upon a review of documentation the surveyor finds that all dampers are not documented. 3-FD1 and 3-FS2 are identified as documented on the 4th Floor but no reference to these damper numbers are identified on the 4th Floor. Damper identification is require by device and not but location. Two additional dampers 5-FD35 and 7-FD29 are identified as not tested.

b. Corrected 11/07/11

B) (New 11/08/11) On 11/08/11, the surveyor observed that the air intake door to S13 was left open to the 9th Floor Mechanical Room. The provider had no reason as to why the intake door was open. The initial filters and the space was filthy and heavily coated with dirt and dust.





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B. 3rd floor surgery electrical closet (3520) defined as a 2 hour rated room on the drawings. This unsprinklered closet contained a duct penetration that was not provided with a fire damper as required for a 2 hour rated enclosure.

6/03/11: The fire damper was installed; however the room was being used for combustible storage (which is not permitted by NFPA 13 in an unsprinklered electrical closet).



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C. Deleted per compliance with earlier edition of NFPA 90A - 11/07/11

A) Modified 06/03/11: Based upon documentation of the most recent semi- annual inspection, the surveyor finds that kitchen hood suppression systems are not installed and/or maintained in accordance with NFPA 17A and NFPA 96:

Corrected 06/03/11

1) Deleted 06/03/11

2) The testing documentation for the last three semi-annual inspections (Revised per documentation of testing for 8-11

a) Corrected 11/08/11

b) Line 48 on the forms for three suppressions systems are not filled out corrected and in accordance with NFPA 17A.

Line 48 is marked "no" This "no"
designation is not explained in accordance
with NFPA 17A on the form. The "no"
is also incorrect; a shunt trip breaker
is required and is provided.

The surveyor notes that one of two electrical
panels in the Lower Level Kitchen appears to
have steam tables and other appliances that
do not require suppression in accordance
with NFPA 17A. This panel has a shunt trip
breaker that does not appear to be required.

c) Line 49 on the forms for three suppressions systems are not filled out corrected and in accordance with NFPA 17A. Detailed information about four of four shut trip breakers (one for each of four of four panels - two at the 1st Floor Servery and two in the Lower Level Kitchen). Some of the information provided is not legible.

d) Deleted 06/03/11

e) Corrected 06/03/11

3) All hood suppression system have electrically fueled appliances that must be disconnected from the fuel source upon activation of each system. Shut trip breakers are installed and tested for each system. Each system has an electrical panel with circuits that identify the appliances on that panel. Below each panel is a main shunt-trip device that disconnects all or part of the panel directly above it.

a) The shunt-trip device located directly below each panel is not clearly identified and also does not clearly identify what is disconnected by the shunt trip device(entire panel above, individual circuits, etc ?).

11/08/11: The above item remains uncorrected; immediate correction is not required.

b) The electrical panel above each shunt-trip device (four of four panels) does not accurately identify the circuit and equipment supplied from the panel. Some of the equipment identified on the panels are no longer installed. Two sets of numbers are used for circuits that do not match. Schedules on panels marked in black marker and panel schedules do not match. Panel schedules with consecutive even and odd circuit numbers do not make sense and are not accurate. Odd number circuits are not identified in the upper portion of the panel door in the space provided with the even number circuits identified in the space provided below. Three pole breakers lack adequate identification.

11/08/11: The above item was not corrected for four of four panels.

B) (New 11/08/11): 1st Floor Servery - a large cart was left in front of Electrical Panel 1LK6' 3'-0" of clear space in front of the panel was not provided (note: this deficiency includes the cart but not the cook).

C) Lower Level Kitchen Main Cooking Line: The four bank fryer lacks 16" of clear from the grill to the left of the fryer in accordance with NFPA 17A.



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Based on direct observation, the surveyor finds:

B. The installation of the kitchen grease duct and utility fans within the 9th floor mechanical penthouse are in non-compliance with NFPA 96, 1998.

1. The connections for the kitchen hood exhaust ducts to the utility fan sets are flexible connections prohibited by NFPA 96, 1998, 5-1.3.

2. The shaft enclosure for the grease ducts from the basement through the floor of the 9th floor mechanical penthouse is not vented to the exterior of the building. (NFPA 96, 4-7.1)

3. The grease duct shaft enclosure within the mechanical penthouse is not continuous to the exterior of the building. The grease ducts penetrate the top of the shaft unprotected to the exterior of the building as prohibited by NFPA 96, 4-7.1.

A) (New 06/02/11) (Modified 11/07/11): The exit access corridor near 774W was obstructed by too many things in the corridor.

B) (New 06/03/11): The 3rd Floor North corridors (3210, 3217 and 3332) were obstructed by beds. carts and equipment.

The above item was not corrected in accordance with the last submitted PoC.

C) (New 11/07/11): The 3rd Floor exit access corridor in front of the Suite that contains O R, 1, 2 and 3 was obstructed by multiple carts including a very large Endo Cabinet on wheels



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Based on random observation during the survey walk-through and staff interview, 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. Carts and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. Eighth Floor:
a. Corrected 11/07/11
b. Corrected 06/02/11
2. Sixth Floor:
a. Corrected 06/02/11
b. Corrected 11/07/11
c. Corrected 06/02/11
d. Corrected 06/02/11
e. (11/07/11) The corridor in front of
Stair # 6 was obstructed on both
sides of the corridor
f. (11/07/11) The corridor with Room
673W was obstructed by mulitple
carts and equipment on stand
(includes three isolation carts)
3. 5th Floor (New 11/07/11)

a. The exit access corridor near
Room 556W was obstrcuted by
carts, stands and equipment.

b. The exit access corridor near
Room 519 was obstrcuted by
carts, stands and equipment.

c. A bed was left in the middle of
the corridor in front of Stair # 2
and the corridor was obstcuted
by carts and stands near Room
536E.


4. Fourth Floor:

a. Corrected 06/02/11.
b. Corrected 06/02/11.
c. Deleted 06/02/11
d. Deleted 06/02/11

5. Second Floor (also refer to K-048):

a. Radiology Unit Corridors 2286,
2339, and 2343, work areas and
equipment.

b. Imaging Unit Corridor 2477, work
stations and equipment.

c. Cardiac Cath Unit Corridor 2199,
work stations and equipment.

d. GI Unit Corridor 2309, equipment.

e. Office Unit Corridor 2201, work
stations.

f. Treatment Unit Corridor 2200, work
stations.

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. 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.

Surveyor 07113:

1. The provider lacks interim life safety measures for all deficiencies observed.

B. (Revised 06/03/11): Basement Level Carpenter Shop: Access was not provided. Surveyor could not confirm one hour fire rated enclosure for a high hazard area and sprinkler head spacing for moderate hazard could not be confirmed.

C. Corrected 06/03/11

D. (New 11/07/11) Adequate interim life safety measures were not found. The provider failed to find and abate the following conditions

1. Fire doors including stair doors were propped open in areas were contractors were working: None of the means used for holding doors open complies with 7.2.1.8.

a. The stair doors for Stair # 4 were wedged
open on three floor (9, 10 and
Penthouse). This resulted in a differential
pressure in the stair that prevented stair
doors on other floors from closing.

b. The fire door to the 10 Floor Elevator
Machine Room was tied open.

c. The 10th Floor Electrical Rooms have
pairs of fire doors. The hardware on
two or three pairs of doors was
` compromised so that the doors would
not latch and the 3rd pair of fire doors
were wedged open. (two doors to
9101E and one door at 9101 W)



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The citation below is cited for the lack of an alternate fuel source and not for the lack of an emergency water plan.

By direct observation the surveyor finds:

The facility failed to provide a means for
providing fuel for heating should the utility
supplied fuel become interrupted as required
by:

The information below is CMS requirements for the above citation.

A703 CFR 482.41(a)(2) There must be facilities for emergency gas and water supply.

(The hospital must have a system to provide emergency gas and water as needed to provide care to inpatients and other persons who may come to the hospital in need of care. This includes making arrangements with local utility companies and others for the provision of emergency sources of water and gas. The hospital should consider nationally accepted references or calculations made by qualified staff when determining the need for at least water and gas. For example, one source for information on water is the Federal Emergency Management Agency (FEMA).

(Emergency gas includes fuels such as propane, natural gas, fuel oil, liquefied natural gas, as well as any gases the hospital uses in the care of patients such as oxygen, nitrogen, nitrous oxide, etc.)

(The hospital should have a plan to protect these limited emergency supplies, and have a plan for prioritizing their use until adequate supplies are available. The plan should also address the event of a disruption in supply (e.g., disruption to the entire surrounding community). .





The proposed completion of this item lacks a phasing schedule with calender dates