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Based on observation, the facility failed to maintain fire rated doors as required by NFPA guidelines.

The evidence includes:

Staff interview and observation during the facility survey walk through on July 28, 2014 revealed that the carpenter's shop door was held open, while unoccupied, by various unapproved devices throughout the work day.

The facility maintenance representative confirmed the finding during the facility survey walk through.

Access to exits is marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. 7.10.1.4

Based on observation, the facility failed to provide exit egress signage as required by NFPA 101.

Observation during the facility survey walk through on July 28, 2014 revealed that the main electrical room secondary egress path through the emergency generator room, was not provided with exit signage.

The facility maintenance representative confirmed the observation during the facility survey walk through.

Based on observation, the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

Observation on the afternoon of July 29 , 2014 revealed the following deficiencies:

1. The double smoke barrier doors labeled 2AB-3B, had a large gap due to warping and misalignment.

2. The double smoke barrier doors labeled 2AB-2A, adjacent to room number 2002, were warped and had an excessive 1" cutout at the bottom as well as an open gap at the astragal greater than the 1/8" maximum allowance.

3. The double smoke barrier doors labeled 2AB-10A, adjacent to gastroenterolgy, required manual assistance to fully close.

4. The double smoke barrier doors labeled 2C-4A, are unable to fully close.

5. The double smoke barrier doors labeled 3AB-2B, required manual assistance to fully close.

The facility maintenance representative confirmed the observations during the facility survey walk through.

Based on observation, the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

Observation on the afternoon of July 29 , 2014 revealed the following deficiencies:

1. The double smoke barrier doors at the second floor adjacent to the exit stairwell between the two buildings were unable to remain in the closed position.

2. The double smoke barrier doors adjacent to room number 224 had an open vertical gap with the doors in the closed position greater than the 1/8" maximum allowance.

The facility maintenance representative confirmed the observations during the facility survey walk through.

Based on observations, the facility failed to maintain the required fire and smoke separation from hazardous areas in conformance with NFPA 101 Section 19.3.2.1.

The evidence includes:

Observations during the facility survey walk through from July 28 to 30, 2014 revealed the following deficiencies:

1. The carpenter's shop corridor double door required manual assistance to fully close and latch.

2. The laundry corridor double door required manual assistance to fully close and latch.

3. The housekeeping, room 1015, corridor double door required manual assistance to fully close and latch.

4. The corridor double doors to the kitchen area, room 1016, has multiple holes and an open gap when closed.

5. The corridor door servicing the copier room, which is utilized for the storage of combustibles is not provided with self-closing and latching hardware

6. The telephone closets throughout the facility house multiple wet electrical transformers which mandate that the corridor doors be provided with self-closing and latching hardware.

7. Storage room number 1006 is utilized for the storage of combustibles and is greater than 50 square feet in floor area is required to have self-closing and latching hardware on the corridor door.

8. Electrical room number 1113 has two large openings which are not fire stopped in the wall common to the egress corridor.

9. The corridor door servicing the sterile storage room number 2085 is not provided with self-closing and latching hardware.

10. The corridor door servicing the sterile storage room number 2085 has a large pass-through cutout which does not larch and is not smoke resistant.

11. The O.R. storage room number 2086 requires manual assistance to fully close and latch.

12. The corridor door servicing the janitor's closet room number 2020 is utilized for the storage of combustibles and is not provided with self-closing and latching hardware.

13. The corridor door servicing the janitor's closet room number 2036 was unable to latch.

14. The electrical closet room at door number 2D-77 has multiple wall penetrations which require firestopping.

The facility maintenance representative confirmed the observations during the survey walk through on July 28, 29 & 30, 2014.

Based on observations, the facility failed to maintain the required fire and smoke separation from hazardous areas in conformance with NFPA 101 Section 19.3.2.1.

The evidence includes:

Observations on the afternoon of July 29, 2014 revealed the following deficiencies:

1. The corridor door servicing the soiled utility room number 223, was unable to fully close and latch without manual assistance.

2. The corridor door servicing the clean utility room number 222, was unable to fully close and latch without manual assistance.

The facility maintenance representative confirmed the observations on July 29, 2014 of the facility survey walk through..

Based on observations, the facility failed to provide complete sprinkler coverage for all portions of the building as required by NFPA 101 Section 19.1.6.

The evidence includes:

A review of available documentation, staff interview and facility survey walk through revealed the following deficiencies:

1. Observations during the facility survey walk through on the afternoon of July 28, 2014 revealed that the installation of fire sprinklers for the loading dock was only partially completed. Full fire sprinkler coverage is required for the loading dock area.

2. Observation during the facility survey walk through on the morning of July 29, 2014 revealed that the fire sprinklers in the elevator machine room have been removed and the piping capped.

The elevator machine room fire construction is rated for one hour and requires fire sprinkler coverage,

The facility maintenance representative confirmed the observations during the facility survey walk through.

The facility has failed to maintain the fire sprinkler system in conformance with NFPA 25 requirements.

The evidence includes:

A review of documentation and staff interview as well as observations during the facility walk through revealed the following deficiencies:

1. The fire standpipe systems throughout the facility were partially inspected on December 22, 2010.

The facility maintenance representative confirmed the finding on July 28, 2014, 2013, during staff interview.

Based on document and plan review as well as the facility survey walkthrough revealed that the facility failed to maintain the HVAC systems in accordance with NFPA guidelines.

The evidence includes:

1. A review of documentation and staff interview on July 29, 2014 revealed that the facility did not maintain the fire/smoke dampers in the HVAC systems in conformance with NFPA guidelines.

The facility is required to document and maintain all fire and smoke dampers in the facility.

A thorough review of the HVAC construction documents followed by physical inspections to verify fire and smoke damper existence and location needs to be undertaken by the facility to develop a complete list of fire and smoke dampers requiring normal maintenance. Floor plans should be maintained to show fire and smoke damper locations throughout the facility.

NFPA 90A recommends that the fire and smoke dampers:

1. Be visually inspected every two years to ensure that they are not rusted or blocked, giving attention to hinges and other moving parts.

2. Be maintained at least every six years by removing the fusible links (where applicable), operating to verify full closure, checking the latch (if provided), and lubricating moving parts as necessary. The fusible links shall be replaced at the completion of the maintenance procedures.

2. Observation during the facility survey walk through revealed that the second floor 90 minute rated double fire doors separating the Main building from the VICC were unable to automatically close and latch due the extreme air pressure differential between the two buildings. The VICC was observed operating at an extreme negative air pressure which impairs multiple components within the structure including but not limited to:

Temperature
Humidity,
Automatic closure of fire doors
Structural degradation due to moisture accumulations inside ceilings and walls
Degradation of electrical components
Surgical suite environment

A review of the VICC construction and As-Built documents and air balancing reports showed that the HVAC air distribution should not be under a negative pressure during normal operation.

The facility maintenance representative confirmed the findings throughout the duration of the facility survey.

Based on observations and staff interview, the facility has failed to maintain the HVAC systems in accordance with NFPA guidelines.

all of the fire and smoke dampers in the HVAC ductwork systems in accordance with NFPA guidelines.

The evidence includes:

1. A review of documentation revealed that the facility was aware of the existence of only the large fire/smoke dampers at the main air handling units. Observations revealed the presence of numerous smaller fire dampers throughout the facility.

The facility is required to document and maintain all fire and smoke dampers in the facility.

A thorough review of the HVAC construction documents followed by physical inspections to verify fire and smoke damper existence and location needs to be undertaken by the facility to develop a complete list of fire and smoke dampers requiring normal maintenance. Floor plans should be maintained to show fire and smoke damper locations throughout the facility.

NFPA 90A recommends that the fire and smoke dampers:

1. Be visually inspected every two years to ensure that they are not rusted or blocked, giving attention to hinges and other moving parts.

2. Be maintained at least every six years by removing the fusible links (where applicable), operating to verify full closure, checking the latch (if provided), and lubricating moving parts as necessary. The fusible links shall be replaced at the completion of the maintenance procedures.

2. Observation on the afternoon of July 28, 2014 during the facility survey walk through revealed that the main electrical room had a growing accumulation of water on the floor from an overflowing HVAC air handling unit condensate drain located in the mechanical room above. The water was observed dripping on the top of an electrical transfer panel which was not in service.

The facility maintenance representative confirmed the observations during the document review and the facility walk through.

Based on observation, the facility failed to maintain the electrical equipment in conformance with NFPA 70 requirements.

The evidence includes:

Observations during the facility walk through revealed the following deficiencies:

1. The electrical transfer switch servicing the main chiller was draped with a combustible plastic sheet.

2. The heat detector servicing the telephone closet adjacent to room number 1008 was inoperable due to the placement of a dust cover.

3. The electrical panels in the telephone closet room number 1065 were obstructed.

4. Electrical closet room number 3041 had exposed three phase wiring not in a conduit and draped over a fire sprinkler head runout.

The facility maintenance representative confirmed the observations on December 3, 2013 of the facility survey walk through.

Based on observation, the facility failed to maintain fire rated doors as required by NFPA guidelines.

The evidence includes:

Staff interview and observation during the facility survey walk through on July 28, 2014 revealed that the carpenter's shop door was held open, while unoccupied, by various unapproved devices throughout the work day.

The facility maintenance representative confirmed the finding during the facility survey walk through.

Access to exits is marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. 7.10.1.4

Based on observation, the facility failed to provide exit egress signage as required by NFPA 101.

Observation during the facility survey walk through on July 28, 2014 revealed that the main electrical room secondary egress path through the emergency generator room, was not provided with exit signage.

The facility maintenance representative confirmed the observation during the facility survey walk through.

Based on observation, the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

Observation on the afternoon of July 29 , 2014 revealed the following deficiencies:

1. The double smoke barrier doors labeled 2AB-3B, had a large gap due to warping and misalignment.

2. The double smoke barrier doors labeled 2AB-2A, adjacent to room number 2002, were warped and had an excessive 1" cutout at the bottom as well as an open gap at the astragal greater than the 1/8" maximum allowance.

3. The double smoke barrier doors labeled 2AB-10A, adjacent to gastroenterolgy, required manual assistance to fully close.

4. The double smoke barrier doors labeled 2C-4A, are unable to fully close.

5. The double smoke barrier doors labeled 3AB-2B, required manual assistance to fully close.

The facility maintenance representative confirmed the observations during the facility survey walk through.

Based on observation, the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

Observation on the afternoon of July 29 , 2014 revealed the following deficiencies:

1. The double smoke barrier doors at the second floor adjacent to the exit stairwell between the two buildings were unable to remain in the closed position.

2. The double smoke barrier doors adjacent to room number 224 had an open vertical gap with the doors in the closed position greater than the 1/8" maximum allowance.

The facility maintenance representative confirmed the observations during the facility survey walk through.

Based on observations, the facility failed to maintain the required fire and smoke separation from hazardous areas in conformance with NFPA 101 Section 19.3.2.1.

The evidence includes:

Observations during the facility survey walk through from July 28 to 30, 2014 revealed the following deficiencies:

1. The carpenter's shop corridor double door required manual assistance to fully close and latch.

2. The laundry corridor double door required manual assistance to fully close and latch.

3. The housekeeping, room 1015, corridor double door required manual assistance to fully close and latch.

4. The corridor double doors to the kitchen area, room 1016, has multiple holes and an open gap when closed.

5. The corridor door servicing the copier room, which is utilized for the storage of combustibles is not provided with self-closing and latching hardware

6. The telephone closets throughout the facility house multiple wet electrical transformers which mandate that the corridor doors be provided with self-closing and latching hardware.

7. Storage room number 1006 is utilized for the storage of combustibles and is greater than 50 square feet in floor area is required to have self-closing and latching hardware on the corridor door.

8. Electrical room number 1113 has two large openings which are not fire stopped in the wall common to the egress corridor.

9. The corridor door servicing the sterile storage room number 2085 is not provided with self-closing and latching hardware.

10. The corridor door servicing the sterile storage room number 2085 has a large pass-through cutout which does not larch and is not smoke resistant.

11. The O.R. storage room number 2086 requires manual assistance to fully close and latch.

12. The corridor door servicing the janitor's closet room number 2020 is utilized for the storage of combustibles and is not provided with self-closing and latching hardware.

13. The corridor door servicing the janitor's closet room number 2036 was unable to latch.

14. The electrical closet room at door number 2D-77 has multiple wall penetrations which require firestopping.

The facility maintenance representative confirmed the observations during the survey walk through on July 28, 29 & 30, 2014.

Based on observations, the facility failed to maintain the required fire and smoke separation from hazardous areas in conformance with NFPA 101 Section 19.3.2.1.

The evidence includes:

Observations on the afternoon of July 29, 2014 revealed the following deficiencies:

1. The corridor door servicing the soiled utility room number 223, was unable to fully close and latch without manual assistance.

2. The corridor door servicing the clean utility room number 222, was unable to fully close and latch without manual assistance.

The facility maintenance representative confirmed the observations on July 29, 2014 of the facility survey walk through..

Based on observations, the facility failed to provide complete sprinkler coverage for all portions of the building as required by NFPA 101 Section 19.1.6.

The evidence includes:

A review of available documentation, staff interview and facility survey walk through revealed the following deficiencies:

1. Observations during the facility survey walk through on the afternoon of July 28, 2014 revealed that the installation of fire sprinklers for the loading dock was only partially completed. Full fire sprinkler coverage is required for the loading dock area.

2. Observation during the facility survey walk through on the morning of July 29, 2014 revealed that the fire sprinklers in the elevator machine room have been removed and the piping capped.

The elevator machine room fire construction is rated for one hour and requires fire sprinkler coverage,

The facility maintenance representative confirmed the observations during the facility survey walk through.

The facility has failed to maintain the fire sprinkler system in conformance with NFPA 25 requirements.

The evidence includes:

A review of documentation and staff interview as well as observations during the facility walk through revealed the following deficiencies:

1. The fire standpipe systems throughout the facility were partially inspected on December 22, 2010.

The facility maintenance representative confirmed the finding on July 28, 2014, 2013, during staff interview.

Based on document and plan review as well as the facility survey walkthrough revealed that the facility failed to maintain the HVAC systems in accordance with NFPA guidelines.

The evidence includes:

1. A review of documentation and staff interview on July 29, 2014 revealed that the facility did not maintain the fire/smoke dampers in the HVAC systems in conformance with NFPA guidelines.

The facility is required to document and maintain all fire and smoke dampers in the facility.

A thorough review of the HVAC construction documents followed by physical inspections to verify fire and smoke damper existence and location needs to be undertaken by the facility to develop a complete list of fire and smoke dampers requiring normal maintenance. Floor plans should be maintained to show fire and smoke damper locations throughout the facility.

NFPA 90A recommends that the fire and smoke dampers:

1. Be visually inspected every two years to ensure that they are not rusted or blocked, giving attention to hinges and other moving parts.

2. Be maintained at least every six years by removing the fusible links (where applicable), operating to verify full closure, checking the latch (if provided), and lubricating moving parts as necessary. The fusible links shall be replaced at the completion of the maintenance procedures.

2. Observation during the facility survey walk through revealed that the second floor 90 minute rated double fire doors separating the Main building from the VICC were unable to automatically close and latch due the extreme air pressure differential between the two buildings. The VICC was observed operating at an extreme negative air pressure which impairs multiple components within the structure including but not limited to:

Temperature
Humidity,
Automatic closure of fire doors
Structural degradation due to moisture accumulations inside ceilings and walls
Degradation of electrical components
Surgical suite environment

A review of the VICC construction and As-Built documents and air balancing reports showed that the HVAC air distribution should not be under a negative pressure during normal operation.

The facility maintenance representative confirmed the findings throughout the duration of the facility survey.

Based on observations and staff interview, the facility has failed to maintain the HVAC systems in accordance with NFPA guidelines.

all of the fire and smoke dampers in the HVAC ductwork systems in accordance with NFPA guidelines.

The evidence includes:

1. A review of documentation revealed that the facility was aware of the existence of only the large fire/smoke dampers at the main air handling units. Observations revealed the presence of numerous smaller fire dampers throughout the facility.

The facility is required to document and maintain all fire and smoke dampers in the facility.

A thorough review of the HVAC construction documents followed by physical inspections to verify fire and smoke damper existence and location needs to be undertaken by the facility to develop a complete list of fire and smoke dampers requiring normal maintenance. Floor plans should be maintained to show fire and smoke damper locations throughout the facility.

NFPA 90A recommends that the fire and smoke dampers:

1. Be visually inspected every two years to ensure that they are not rusted or blocked, giving attention to hinges and other moving parts.

2. Be maintained at least every six years by removing the fusible links (where applicable), operating to verify full closure, checking the latch (if provided), and lubricating moving parts as necessary. The fusible links shall be replaced at the completion of the maintenance procedures.

2. Observation on the afternoon of July 28, 2014 during the facility survey walk through revealed that the main electrical room had a growing accumulation of water on the floor from an overflowing HVAC air handling unit condensate drain located in the mechanical room above. The water was observed dripping on the top of an electrical transfer panel which was not in service.

The facility maintenance representative confirmed the observations during the document review and the facility walk through.

Based on observation, the facility failed to maintain the electrical equipment in conformance with NFPA 70 requirements.

The evidence includes:

Observations during the facility walk through revealed the following deficiencies:

1. The electrical transfer switch servicing the main chiller was draped with a combustible plastic sheet.

2. The heat detector servicing the telephone closet adjacent to room number 1008 was inoperable due to the placement of a dust cover.

3. The electrical panels in the telephone closet room number 1065 were obstructed.

4. Electrical closet room number 3041 had exposed three phase wiring not in a conduit and draped over a fire sprinkler head runout.

The facility maintenance representative confirmed the observations on December 3, 2013 of the facility survey walk through.