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

Findings include:

A. The Third Floor Sitting Room, which was observed to constitute a waiting area open to the corridor and to not be visible from a constantly attended station, was observed to lack a smoke detector required by Exception 2. [subpart (b)] to 19.3.6.1.

B. The First Floor Radiology Department Nurses' Station, which was observed to constitute a staff work area open to the smoke compartment corridors, was observed to lack a smoke detector required by Exception 1. [subpart (c)] to 19.3.6.1. Surveyor 14290 notes that, during an interview conducted at the site on the morning of November 9, 2010, the provider's radiology staff confirmed that the Nurses' Station is not constantly attended.

Based on random observation during the survey walk-through and staff interview, not ventilation or other shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. The following deficiencies were observed at a pipe shaft on the Third Floor, located directly across from Exit Stair E-A (at which pipes were observed to not be sealed against the passage of fire at the floor):

1. During an interview held at the site, the provider's Director of Plant Services could not confirm that the shaft, which consists of metal lath and plaster, carries a minimum 1 hour fire rating as required by 8.2.5.4.
2. The access door to the shaft was observed to not be self-closing as required by 8.2.3.2.3.1(2).

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1.

Findings include:

A. Hazardous areas not 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 (all Second Floor):

1. Psychiatric Unit:
a. Linen Closet.

b. Clean Utility Room.

2. Med Surg Unit West Linen Room.

B. Doors to hazardous areas not covered by a sprinkler system were observed to not carry a minimum fire resistance rating of 3/4 hour as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include:

1. Second Floor Psych Unit Soiled Utility Room.

2. First Floor Same Day Surgery Unit, 2 former Delivery Rooms now used as storage rooms.

C. The First Floor Outpatient Clinic File Storage Room, which was observed to constitute a hazardous area not covered by a sprinkler sytem, was observed to not be separated from the remainder of the building with a minimum 1 hour fire rated enclosure as required by 19.3.2.1. because:
1. The door to the room was observed to not carry a minimum 3/4 hour fire rating required by 8.2.3.2.3.1(2).
2. An unprotected interior window opening was observed as prohibited by 8.2.3.2.3.1(2).

Based on random observation during the survey walk-through, not all laboratories employing quantities of flammable, combustible, or hazardous materials are protected in accordance with NFPA 99.

Findings include:

A. The travel distance from the most remote point of the First Floor Laboratory to an exit access door was observed to be in excess of 75'-0" as prohibited by NFPA 99 1999 10-3.2.2.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. Doors in exit stair enclosures which are 4 stories in height or more were observed which could not be confirmed as carrying a minimum 1-1/2 hour fire resistance rating, as required by 8.2.5.4(1) and 8.2.3.2.3.1(1), because the labels attached to the doors did not indicate their level of fire resistance rating. Locations observed include:

1. Third Floor:
a. Exit Stair E-A.
b. Exit Stair E-C.

c. Exit Stair E-G.

2. Second Floor:

a. Exit Stair E-A.
b. Exit Stair E-C.

3. First Floor Exit Stair E-A.

4. Basement Level Exit Stair E-A.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. The Elevator Penthouse above the Third Floor was observed to be served solely by an exit stair which discharges interior to the building (Exit Stair E-C), and is thus not complete to a public way as required by 7.7.1.

B. The pair of doors to the First Floor Laboratory were observed to be equipped with a thumbturn deadbolt retractor, thus requiring more than 1 door releasing operation as prohibited by 7.2.1.5.4.

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

Findings include:

A. Egress paths for the Second Floor Intensive Care Unit, which constitutes a suite of patient sleeping rooms which are provided with direct visual supervision, was observed to pass through more than 1 intervening room as prohibited by Exception 3. to 19.2.5.1. The egress paths which require passage through more than 1 intervening room include:
1. The egress path through the Vestibule for the Chapel.

2. The egress path through the Vestibule for the Waiting Room.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. The Elevator Penthouse above the Third Floor was observed to lack heat detectors within 2'-0" of sprinkler heads as required by NFPA 72 1999 3-9.4.2.

B. Fire alarm manual pulls stations were observed throughout the facility which are located more than 4'-6" above the floor as prohibited by NFPA 72 1999 2-8.1.

C. The Basement Electrical Room housing the building Fire Alarm Control Panel (adjacent to the Office of the Director of Plant Services), which was observed to not be continuously occupied, was observed to lack a smoke detector required by NFPA 72 1999 1-5.6.

D. At the Second Floor Med Surg Unit, the fire alarm system audible alarm was not at least 10 dBA above the ambient noise level as required by NFPA 72 1999 4-3.3.2.

Based on document review and staff interview, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6.

Findings include:

A. Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis as required by NFPA 72 1999 7-3.2. During an interview held in his Office on the afternoon of November 9, 2010, the provider's Director of Plant Services confirmed that 25 per cent of all fire alarm initiation devices are tested by an outside vendor each quarter. Review of the 4 most recent vendor-provided quarterly reports indicated that in each case, several devices were listed as not having been tested. However, none of the reports reviewed showed that these devices had been tested under a subsequent test. Therefore, not all fire alarm initiation devices are tested at least annually as required.

Based on random observation during the survey walk-through, not all linen or refuse chutes are constructed an maintained as fire resistive assemblies.

Findings include:

A. The following deficiencies were observed at the Basement Level Soiled Linen Chute Discharge Room:

1. Two ducts were observed which lack fire dampers required by 8.2.3.2.4.1. and NFPA 82 1999 3-2.4.3.

2. The door to the room was observed to not carry a minimum 1-1/2 hour fire resistance rating required by 8.2.3.2.3.1(1) and NFPA 82 1999 3-2.6.1.

Based on random observation during the survey walk-through, 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, furnishings, 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. Third Floor Nurses' Station:

a. Two medication carts.

b. Two chairs.

2. Second Floor Med Surg Unit:
a. Northwest Corridor: Linen hampers and medical equipment plugged in and charging.

b. Southwest Corridor: Linen hampers and medical equipment plugged in and charging.

3. First Floor Corridor in Same Day Surgery Unit, medication cart.

Based on random observation during the survey walk-through and staff interview, the building's emergency generator is not installed and maintained in accordance with NFPA 99.

Findings include:

A. The emergency generator was observed to lack a remote manual stop station, located outside the room housing the generator, as required by NFPA 110 1999 3-5.5.6. During an interview held at the site on the afternoon of November 8, 2010, the provider's Director of Plant Services confirmed this observation.

B. The room housing the emergency generator was observed to lack a battery-powered emergency light required by NFPA 70 1999 517-32.(e), NFPA 99 1999 3-4.2.2.2.(b)(5), and NFPA 110 1999 5-3.1. During an interview held at the site on the afternoon of November 8, 2010, the provider's Director of Plant Services confirmed this observation.

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.

B. The enclosure walls for the Basement Level Electrical Room housing the Fire Alarm Control Panel (adjacent to the Office of the Director of Plant Services) were observed to not be complete to the deck above, which compromises the room's sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1.

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. The building's primary electrical switchgear, located in the Basement Level Central Stores Room, was observed to not be separated from the stored materials as required by 19.3.2.1. and NFPA 70 1999 384-7.

Based on random observation during the survey walk-through and staff interview, not all elevators within the facility conform with firefighters' service requirements of ANSI/ASME A17.3.

Findings include:

A. The North Elevators were observed to lack Phase II firefighters' service, including in-car operation, required by ANSI/ASME A17.1 1993 211.3(c). During an interview held at the First Floor Elevator Lobby on the afternoon of November 8, 2010, the provider's Director of Plant Services confirmed this observation.

C. Elevator lobbies were observed to lack smoke detectors which comply with 19.5.3., 9.4.3.2., ANSI/ASME A17.3 1993 3.11.3. and ANSI/ASME A17.1 1993 211.3(b). During an interview held at the First Floor Elevator Lobby on the afternoon of November 8, 2010, the provider's Director of Plant Services confirmed this observation. Locations observed include all Elevator Lobbies serving the North Elevators.

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

Findings include:

A. The Third Floor Sitting Room, which was observed to constitute a waiting area open to the corridor and to not be visible from a constantly attended station, was observed to lack a smoke detector required by Exception 2. [subpart (b)] to 19.3.6.1.

B. The First Floor Radiology Department Nurses' Station, which was observed to constitute a staff work area open to the smoke compartment corridors, was observed to lack a smoke detector required by Exception 1. [subpart (c)] to 19.3.6.1. Surveyor 14290 notes that, during an interview conducted at the site on the morning of November 9, 2010, the provider's radiology staff confirmed that the Nurses' Station is not constantly attended.

Based on random observation during the survey walk-through and staff interview, not ventilation or other shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. The following deficiencies were observed at a pipe shaft on the Third Floor, located directly across from Exit Stair E-A (at which pipes were observed to not be sealed against the passage of fire at the floor):

1. During an interview held at the site, the provider's Director of Plant Services could not confirm that the shaft, which consists of metal lath and plaster, carries a minimum 1 hour fire rating as required by 8.2.5.4.
2. The access door to the shaft was observed to not be self-closing as required by 8.2.3.2.3.1(2).

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1.

Findings include:

A. Hazardous areas not 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 (all Second Floor):

1. Psychiatric Unit:
a. Linen Closet.

b. Clean Utility Room.

2. Med Surg Unit West Linen Room.

B. Doors to hazardous areas not covered by a sprinkler system were observed to not carry a minimum fire resistance rating of 3/4 hour as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include:

1. Second Floor Psych Unit Soiled Utility Room.

2. First Floor Same Day Surgery Unit, 2 former Delivery Rooms now used as storage rooms.

C. The First Floor Outpatient Clinic File Storage Room, which was observed to constitute a hazardous area not covered by a sprinkler sytem, was observed to not be separated from the remainder of the building with a minimum 1 hour fire rated enclosure as required by 19.3.2.1. because:
1. The door to the room was observed to not carry a minimum 3/4 hour fire rating required by 8.2.3.2.3.1(2).
2. An unprotected interior window opening was observed as prohibited by 8.2.3.2.3.1(2).

Based on random observation during the survey walk-through, not all laboratories employing quantities of flammable, combustible, or hazardous materials are protected in accordance with NFPA 99.

Findings include:

A. The travel distance from the most remote point of the First Floor Laboratory to an exit access door was observed to be in excess of 75'-0" as prohibited by NFPA 99 1999 10-3.2.2.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. Doors in exit stair enclosures which are 4 stories in height or more were observed which could not be confirmed as carrying a minimum 1-1/2 hour fire resistance rating, as required by 8.2.5.4(1) and 8.2.3.2.3.1(1), because the labels attached to the doors did not indicate their level of fire resistance rating. Locations observed include:

1. Third Floor:
a. Exit Stair E-A.
b. Exit Stair E-C.

c. Exit Stair E-G.

2. Second Floor:

a. Exit Stair E-A.
b. Exit Stair E-C.

3. First Floor Exit Stair E-A.

4. Basement Level Exit Stair E-A.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. The Elevator Penthouse above the Third Floor was observed to be served solely by an exit stair which discharges interior to the building (Exit Stair E-C), and is thus not complete to a public way as required by 7.7.1.

B. The pair of doors to the First Floor Laboratory were observed to be equipped with a thumbturn deadbolt retractor, thus requiring more than 1 door releasing operation as prohibited by 7.2.1.5.4.

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

Findings include:

A. Egress paths for the Second Floor Intensive Care Unit, which constitutes a suite of patient sleeping rooms which are provided with direct visual supervision, was observed to pass through more than 1 intervening room as prohibited by Exception 3. to 19.2.5.1. The egress paths which require passage through more than 1 intervening room include:
1. The egress path through the Vestibule for the Chapel.

2. The egress path through the Vestibule for the Waiting Room.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

Findings include:

A. The Elevator Penthouse above the Third Floor was observed to lack heat detectors within 2'-0" of sprinkler heads as required by NFPA 72 1999 3-9.4.2.

B. Fire alarm manual pulls stations were observed throughout the facility which are located more than 4'-6" above the floor as prohibited by NFPA 72 1999 2-8.1.

C. The Basement Electrical Room housing the building Fire Alarm Control Panel (adjacent to the Office of the Director of Plant Services), which was observed to not be continuously occupied, was observed to lack a smoke detector required by NFPA 72 1999 1-5.6.

D. At the Second Floor Med Surg Unit, the fire alarm system audible alarm was not at least 10 dBA above the ambient noise level as required by NFPA 72 1999 4-3.3.2.

Based on document review and staff interview, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6.

Findings include:

A. Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis as required by NFPA 72 1999 7-3.2. During an interview held in his Office on the afternoon of November 9, 2010, the provider's Director of Plant Services confirmed that 25 per cent of all fire alarm initiation devices are tested by an outside vendor each quarter. Review of the 4 most recent vendor-provided quarterly reports indicated that in each case, several devices were listed as not having been tested. However, none of the reports reviewed showed that these devices had been tested under a subsequent test. Therefore, not all fire alarm initiation devices are tested at least annually as required.

Based on random observation during the survey walk-through, not all linen or refuse chutes are constructed an maintained as fire resistive assemblies.

Findings include:

A. The following deficiencies were observed at the Basement Level Soiled Linen Chute Discharge Room:

1. Two ducts were observed which lack fire dampers required by 8.2.3.2.4.1. and NFPA 82 1999 3-2.4.3.

2. The door to the room was observed to not carry a minimum 1-1/2 hour fire resistance rating required by 8.2.3.2.3.1(1) and NFPA 82 1999 3-2.6.1.

Based on random observation during the survey walk-through, 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, furnishings, 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. Third Floor Nurses' Station:

a. Two medication carts.

b. Two chairs.

2. Second Floor Med Surg Unit:
a. Northwest Corridor: Linen hampers and medical equipment plugged in and charging.

b. Southwest Corridor: Linen hampers and medical equipment plugged in and charging.

3. First Floor Corridor in Same Day Surgery Unit, medication cart.

Based on random observation during the survey walk-through and staff interview, the building's emergency generator is not installed and maintained in accordance with NFPA 99.

Findings include:

A. The emergency generator was observed to lack a remote manual stop station, located outside the room housing the generator, as required by NFPA 110 1999 3-5.5.6. During an interview held at the site on the afternoon of November 8, 2010, the provider's Director of Plant Services confirmed this observation.

B. The room housing the emergency generator was observed to lack a battery-powered emergency light required by NFPA 70 1999 517-32.(e), NFPA 99 1999 3-4.2.2.2.(b)(5), and NFPA 110 1999 5-3.1. During an interview held at the site on the afternoon of November 8, 2010, the provider's Director of Plant Services confirmed this observation.

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.

B. The enclosure walls for the Basement Level Electrical Room housing the Fire Alarm Control Panel (adjacent to the Office of the Director of Plant Services) were observed to not be complete to the deck above, which compromises the room's sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1.

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999.

Findings include:

A. The building's primary electrical switchgear, located in the Basement Level Central Stores Room, was observed to not be separated from the stored materials as required by 19.3.2.1. and NFPA 70 1999 384-7.

Based on random observation during the survey walk-through and staff interview, not all elevators within the facility conform with firefighters' service requirements of ANSI/ASME A17.3.

Findings include:

A. The North Elevators were observed to lack Phase II firefighters' service, including in-car operation, required by ANSI/ASME A17.1 1993 211.3(c). During an interview held at the First Floor Elevator Lobby on the afternoon of November 8, 2010, the provider's Director of Plant Services confirmed this observation.

C. Elevator lobbies were observed to lack smoke detectors which comply with 19.5.3., 9.4.3.2., ANSI/ASME A17.3 1993 3.11.3. and ANSI/ASME A17.1 1993 211.3(b). During an interview held at the First Floor Elevator Lobby on the afternoon of November 8, 2010, the provider's Director of Plant Services confirmed this observation. Locations observed include all Elevator Lobbies serving the North Elevators.