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Based on observation and staff interview, the facility did not ensure that all doors in an exit passageway, horizontal exit, and smoke barrier are held open by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of local smoke detectors designed to detect smoke passing through the opening.

Findings include but was not limited to:

1. There was no smoke heads on the two sides of the smoke doors on the corridor next to room 1025 and 1024.

2. There was no strobe light in the patient shower of the 10th floor.

All the above findings were identified in the presence of the hospital's director of Facilities who acknowledged them.

Based on observation and staff interview, access exits was not marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to occupants.

The finding included:

1. During a tour of the facility on the afternoon of 4/26/2012, it was observed that the Mechanical room (approximately 2000 SQ FT) on the 4th floor did not have exit
signs to direct the staff to outside the room in the event of fire or smoke.

The above finding was identified in the presence of the hospital's director of facilities who acknowledged this finding.

Based on observation and staff interview, the facility failed to ensure that the smoke and fire barriers of the hospital are intact.

Findings include but were not limited to:

1. The wall of the smoke barrier on top of the smoke doors T1049 was found to have penetrations at part of the wall that meet the ceiling.

2. Penetrations of the smoke barrier were noted on the wall on top of smoke door T1042 and were sealed by insulation and lacked the proper fire stop.

3. The one hour fire rated wall on the corridor of the vascular unit on top of vascular laboratory T927 had penetrations at the joints of the wall with the ceiling.
This penetration had insulation and did not have the proper fire stop.

4. The one hour fire rated wall of storage room 948 had a penetration that was > 8 inches wide.

5. The two hour fire rated wall above the rear stairwell D had penetrations at the joint of the wall and the ceiling that had only insulation and lacked the proper fire stops.

6. The one hour fire rating wall of the electric equipment room #19 "CPB012" had multiple penetrations around 4 conduits to the left of the door that were not sealed by fire stops.

7. There was an opening (penetration) around and above a fire damper that was about 2 feet x 10 feet. Also, the fire rated wall at the corridor next to the fire panel room had numerous penetrations.

8. The two hour fire rated wall in the mechanical shop and the phone room in the basement, had multiple penetrations that were not sealed by fire stop.

9. The fire walls of the electrical room TB062 in the radiology suite had a big penetration that was > 1 foot wide around conduits. Also, there were penetrations at the walls meeting with the deck that were not sealed by fire stops.

10. The smoke barrier of the wall above the smoke door CP226 had multiple penetrations around conduits and in other locations of the wall that were not sealed by fire stops, and therefore compromise the smoke barrier.

All the above findings were identified in the presence of the hospital's director of Facilities who acknowledged them.

Based on observation and staff interview, the hospital did not ensure that the storage room was of a one hour fire rated construction or an approved automatic fire extinguishing system. as per NFPA 101 8.4.1 and /or 19.3.5.4

Findings include:

1. The corridor between the surgical suite (OR) and the central sterile supply had an alcove that was used for storing an anesthesia machine, many empty cases of endoscopes stored on a rack which extends from the floor to the ceiling, Carbon Dioxide cylinders, Nitrous Oxide cylinders and Oxygen cylinders. Storing of all these supplies in the alcove presents a fire hazard.

2. During a tour of the hospital on the morning of 4/25/2012, it was observed that the hospital stored two huge plastic containers full of clean linen on the back of the elevator bank D.

All the above findings were identified in the presence of the hospital's director of Facilities who acknowledged them.

Based on observation and staff interview, the facility failed to maintain corridors clear and free of obstructions to ensure safe and timely evacuation in the event of fire.

Findings include:

1. The corridor which is the second means of egress for the surgical suite was noted to be used (converted) as a storage room that housed many boxes full of supplies.

2. The fire and smoke door on the surgical suite corridor was replaced by a 3 feet door that is not wide enough to permit a timely evacuation of the surgical suite in the event of a fire.

3. The facility converted two rooms (room T306 and room T307) from the pediatric unit into an adult ICU room. The facility used the corridor that serve as the second mean of egress of the pediatric unit in front of those two rooms as an office. That corridor was observed to house a disk, 7 chairs, a cart etc., This is a fire safety hazard and compromise the timely evacuation in the event of fire.

5. The corridor of the ED to the clinic was observed to be blocked by 3 stretchers, a housekeeping cart, a linen cart, etc. There was only 2 ? feet of a clear space left from the corridor.

All the above findings were identified in the presence of the hospital's director of Facilities who acknowledged them.

Based on observation and staff interview, the facility did not comply with the provisions of NFPA 101 10.3.1

The finding included:

The seclusion room of the geriatric psych unit was found to have a carpet lining its four walls. The flame spread rating of that carpet could not be provided. Covering the seclusion room with carpets of unknown flame spread rating is a fire safety hazard.

The above finding was identified in the presence of the Hospital's Director of Facilities who acknowledged the deficiency.

Based on observation and staff interview, the facility did not ensure that all doors in an exit passageway, horizontal exit, and smoke barrier are held open by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of local smoke detectors designed to detect smoke passing through the opening.

Findings include but was not limited to:

1. There was no smoke heads on the two sides of the smoke doors on the corridor next to room 1025 and 1024.

2. There was no strobe light in the patient shower of the 10th floor.

All the above findings were identified in the presence of the hospital's director of Facilities who acknowledged them.

Based on observation and staff interview, access exits was not marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to occupants.

The finding included:

1. During a tour of the facility on the afternoon of 4/26/2012, it was observed that the Mechanical room (approximately 2000 SQ FT) on the 4th floor did not have exit
signs to direct the staff to outside the room in the event of fire or smoke.

The above finding was identified in the presence of the hospital's director of facilities who acknowledged this finding.

Based on observation and staff interview, the facility failed to ensure that the smoke and fire barriers of the hospital are intact.

Findings include but were not limited to:

1. The wall of the smoke barrier on top of the smoke doors T1049 was found to have penetrations at part of the wall that meet the ceiling.

2. Penetrations of the smoke barrier were noted on the wall on top of smoke door T1042 and were sealed by insulation and lacked the proper fire stop.

3. The one hour fire rated wall on the corridor of the vascular unit on top of vascular laboratory T927 had penetrations at the joints of the wall with the ceiling.
This penetration had insulation and did not have the proper fire stop.

4. The one hour fire rated wall of storage room 948 had a penetration that was > 8 inches wide.

5. The two hour fire rated wall above the rear stairwell D had penetrations at the joint of the wall and the ceiling that had only insulation and lacked the proper fire stops.

6. The one hour fire rating wall of the electric equipment room #19 "CPB012" had multiple penetrations around 4 conduits to the left of the door that were not sealed by fire stops.

7. There was an opening (penetration) around and above a fire damper that was about 2 feet x 10 feet. Also, the fire rated wall at the corridor next to the fire panel room had numerous penetrations.

8. The two hour fire rated wall in the mechanical shop and the phone room in the basement, had multiple penetrations that were not sealed by fire stop.

9. The fire walls of the electrical room TB062 in the radiology suite had a big penetration that was > 1 foot wide around conduits. Also, there were penetrations at the walls meeting with the deck that were not sealed by fire stops.

10. The smoke barrier of the wall above the smoke door CP226 had multiple penetrations around conduits and in other locations of the wall that were not sealed by fire stops, and therefore compromise the smoke barrier.

All the above findings were identified in the presence of the hospital's director of Facilities who acknowledged them.

Based on observation and staff interview, the hospital did not ensure that the storage room was of a one hour fire rated construction or an approved automatic fire extinguishing system. as per NFPA 101 8.4.1 and /or 19.3.5.4

Findings include:

1. The corridor between the surgical suite (OR) and the central sterile supply had an alcove that was used for storing an anesthesia machine, many empty cases of endoscopes stored on a rack which extends from the floor to the ceiling, Carbon Dioxide cylinders, Nitrous Oxide cylinders and Oxygen cylinders. Storing of all these supplies in the alcove presents a fire hazard.

2. During a tour of the hospital on the morning of 4/25/2012, it was observed that the hospital stored two huge plastic containers full of clean linen on the back of the elevator bank D.

All the above findings were identified in the presence of the hospital's director of Facilities who acknowledged them.

Based on observation and staff interview, the facility failed to maintain corridors clear and free of obstructions to ensure safe and timely evacuation in the event of fire.

Findings include:

1. The corridor which is the second means of egress for the surgical suite was noted to be used (converted) as a storage room that housed many boxes full of supplies.

2. The fire and smoke door on the surgical suite corridor was replaced by a 3 feet door that is not wide enough to permit a timely evacuation of the surgical suite in the event of a fire.

3. The facility converted two rooms (room T306 and room T307) from the pediatric unit into an adult ICU room. The facility used the corridor that serve as the second mean of egress of the pediatric unit in front of those two rooms as an office. That corridor was observed to house a disk, 7 chairs, a cart etc., This is a fire safety hazard and compromise the timely evacuation in the event of fire.

5. The corridor of the ED to the clinic was observed to be blocked by 3 stretchers, a housekeeping cart, a linen cart, etc. There was only 2 ? feet of a clear space left from the corridor.

All the above findings were identified in the presence of the hospital's director of Facilities who acknowledged them.

Based on observation and staff interview, the facility did not comply with the provisions of NFPA 101 10.3.1

The finding included:

The seclusion room of the geriatric psych unit was found to have a carpet lining its four walls. The flame spread rating of that carpet could not be provided. Covering the seclusion room with carpets of unknown flame spread rating is a fire safety hazard.

The above finding was identified in the presence of the Hospital's Director of Facilities who acknowledged the deficiency.