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By direct observation the surveyor finds:

A. Corrected 10/10/08.
B. Corrected 07/01/09.

C. West building: Toilet exhaust duct risers for floors 2 through 6 could not be confirmed to be installed within rated shaft assemblies. Example location observed: Fifth floor West Wing - bathroom between patient rooms #536 and #537.
UPDATE 4/7/09: The surveyor observed dampers in the 2nd and 5th floor. In Room 526, the duct did not have an angle bracket or any means of support. The installation of the damper can not be verified as compliant with any UL#.







16339


D. 1. Corrected 4/7/09.
E. Corrected 10/10/08.


20224


F. Corrected 10/10/08.

A. By direct observation, staff interview and review of facility provided documents (third party damper survey) the surveyor finds: All identified locations for fire dampers and fire/smoke dampers for duct penetration from shafts or vertical openings, either lack access panels or improperly installed access panels as required by NFPA 90A, 1999, 2-3.4.1 that allow for verification, inspection and maintenance of the fire dampers installations.
Locations are but not limited to:

1. Corrected 4/7/09

2. Toilet exhaust risers West building as observed on 5th Floor.
UPDATE 4/7/09: Refer to K-020-C.

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.