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Based on observation and interview, the facility did not provide a common Separation Barrier with doors of positive-latching hardware, sealed wall penetrations and fire-rated wall construction. These deficiencies occurred in 5 of the 74 smoke compartments for this health care facility and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

4. On 04/21/2015 at 1:08 pm, observation revealed on the 3rd floor in 3101-Corridor between SC-3D & SC-3B/3F, that penetrations were not sealed according to an approved method. The deficiencies included multiple penetrations of pipes, conduits, and wires not properly fire-sealed through a 2-hour Separation Barrier above the ceiling at the double door set and adjoining wall next to Children/Parents Lounge Room 3216. Observed metal screws not all double mudded or gypsum wallboard seams taped. These observed situations were not compliant with NFPA 101 (2000 ed.), sections 18.1.1.4 & 8.2.3.2.4.

5. On 04/21/2015 at 9:42 am, observation revealed on the 4th floor in 4126-Corridor at 2-hour Separation Barrier between CMS Buildings #02 & #01 at SC-4E & SC-4G, that penetrations were not sealed according to a UL approved method. These deficiencies included the horizontal lid of the 2-hour deck that was not properly fire-sealed where it met the vertical wall above the ceiling. Also observed 5 pipes not properly fire-sealed though the 2-hour Separation Barrier (masonry construction) used between two different buildings. These observed situations were not compliant with NFPA 101 (2000 ed.), sections 18.1.1.4 & 8.2.3.2.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based on observation and interview, the facility did not provide a common separation wall with taped joints on rated walls. This deficiency occurred in 1 of the 74 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 04/21/2015 at 1:51 pm, observation revealed on the 3rd floor in the Center Wing Separation Wall & Smoke Barrier in SC-3F, that the enclosing wall was not constructed to a 2-hour fire resistance rating because not all the drywall screws were covered with joint compound as required for designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.1.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based on interview and documentation review, the facility did not provide the minimum construction type for a 4-story building. The floors were only fire-rated to 1-hour construction. This deficiency occurred in 5 of the 74 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 08/06/2015 at approximately 3:00 pm, a letter dated January 5, 2005 was given to surveyor #18107 by staff KK, identifying that this CMS Building #01 is not fire-rated to the required Type II (222). The letter states it could only be classified as a TYPE II (111) or possibly a "hybrid - (221)" structure. The Center Wing flooring/ceiling system in Smoke Compartments - A6, 1F, 2F, 3F & 4G was not constructed to a 2-hour fire resistance rating. These observed situations were not compliant with NFPA 101 (2000 ed.), sections 19.1.6.2 and 19.1.1.4. These conditions were confirmed at the time of discovery by a concurrent interview and documentation review with staff JJ (Maintenance Manager), staff LL (Director Project Mgmt.), staff KK (Power Plant Manager) and staff O (IP Product Specialist-RN).
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Based on observation and interview, the facility did not provide and maintain the required building construction type, Type II (222), with support steel covered with 2-hour rated fire-proofing, matching the same construction type on all floors of the CMS Building #02. These deficiencies occurred in 3 of the 74 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

2. On 04/21/2015 at 2:40 pm, observation revealed that one building construction type was "stacked" above a different type of construction on the next lower floor, which may affect the structural fire-resistance and stability of the North Wing component of CMS Building #02. Surveyor was told by staff LL that drawings showed steel rods were drilled into the adjoining concrete slab floor system to support the new concrete floor system and the exposed steel decking was used to support the poured-in-place concrete floor system. However, no drawings were shared with the surveyor and this could not be verified. The 4-Story Shaft was missing the proper fire-proofing due to the metal lath and plaster having been removed that provided the 2-hour fire-protection for this 4-Story Building, Type II (222), built in 1926. All floors need to be verified they are built to the required Type II (222) construction, where shaft metal lath and plaster was removed in past renovations. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.1.6.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in spaces that are open to the corridor, and compliant corridor wall construction at highrise elevator lobbies. These deficiencies occurred in 5 of the 74 smoke compartments at this hospital campus, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/21/2015 at 9:25 am, observation revealed on the 5th floor in the 4'x10' Open Alcove, that the area was not separated from the exit egress corridor by smoke-tight wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector, as an alternative, and was not fully-observable from a 24-hour occupied location. These observed situations were not compliant with NFPA 101 (2000 ed.), section 18.3.6.1. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

2. On 04/21/2015 at 10:45 am, observation revealed on the 5th floor in the Vending Machine Alcove 5602, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector, as an alternative, and was not fully-observable from a 24-hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

3. On 08/06/2015 during the morning tour for the monitoring verification visit from the original survey on 04/20/2015 at 10:17 am, observation revealed on the 4th floor in the 4106A-Highrise Elevator Lobby in Smoke Compartment-4B, that the corridor wall at door set 4601A was not completed as yet. The Elevator Lobby walls must be smoke-tight for high-rise construction. This building added 2-Floors (Inpatient Units) with a Elevator Mechanical Penthouse in 2004 that pushed the height of the tallest floor above 75'-0" above grade, requiring all elevator lobbies to be enclosed and smoke-tight. Above the ceiling the walls were not smoke-tight with numerous penetrations of pipes, conduits, wires and ducts not properly smoke-sealed. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

4. On 08/06/2015 during the afternoon tour for the monitoring verification visit from the original survey on 04/21/2015 at 12:11 pm, observation revealed on the 3rd floor at the 3601A-Highrise Elevator Lobby in Smoke Compartment-3B, that the corridor wall was not compliant because the wall must be smoke-tight for high-rise construction. This building added 2 Floors (Inpatient Units) with a Elevator Mechanical Penthouse in 2004 that pushed the height of the tallest floor above 75'-0" above grade, requiring all elevator lobbies to be enclosed and smoke-tight. Above the ceiling the walls were not smoke-tight because the top-of-wall was not smoke-sealed above a duct. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff LL (Director Project Mgmt.).

5. On 04/22/2015 at 11:00 am, observation revealed on the 2nd floor at the 2601C- Highrise Elevator Lobby door set in Smoke Compartment-2B, that the corridor wall was not compliant because the wall must be smoke-tight for high-rise construction. This building added 2 Floors (Inpatient Units) with a Elevator Mechanical Penthouse in 2004 that pushed the height of the tallest floor above 75'-0" above grade, requiring all elevator lobbies to be enclosed and smoke-tight. Above the ceiling the walls were not smoke-tight with numerous penetrations of pipes, conduits, wires and ducts not properly smoke-sealed. Based on the cummulative observations from these three floor elevator lobbies in the Southwest Wing, all the lobbies in this addition need to be verified to be smoke-tight. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

6. On 04/22/2015 at 9:57 am, observation revealed on the 3rd floor in the Pediatric Procedure Suite (2,669 SF) in Smoke Compartment-3C, that the corridor wall was not compliant because the suite was required to be smoke-tight to the corridor and numerous penetrations were observed from sprinkler pipes, drywall patches not taped and screws not mudded. This area was recently remodeled to new construction. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).
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29942

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in spaces that are open to the corridor, and no combustible material storage. This deficiency occurred in 4 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/22/2015 at 9:05 am, observation revealed on the 2nd floor in the Reception room number 2975, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

2. On 04/21/2015 at 2:45 pm, observation revealed on the 5th floor in the Reception located in smoke compartment 5H, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

3. On 04/21/2015 at 3:05 pm, observation revealed on the 5th floor in the Room number 5934B, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

4. On 04/21/2015 at 3:07 pm, observation revealed on the 5th floor in the Room Number 5970A, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

5. On 04/21/2015 at 3:15 pm, observation revealed on the 2nd floor in the Vending machine space 2904B, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

6. On 04/21/2015 at 3:30 pm, observation revealed on the 2nd floor in the Reception located in smoke compartment 2J, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that are open to the corridor. The space did not have a smoke detector and, as an alternative, was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).
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Based on observation and interview, the facility did not provide corridor separation doors with code compliant corridor doors. These deficiencies occurred in 4 of the 74 smoke compartments within this hospital campus, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/21/2015 at 2:30 pm, observation revealed on the 3rd floor in the Smoke Compartment-3I, North Wing, built in 1926, that the corridor was not compliant. During the survey tour it was explained that this wall of the office was on a smoke barrier between SC-3I & SC-3G. However, the Life Safety Plans did not show it this way. As a wall to the corridor this wall still had to be smoke-tight, which it was not. Observed a three (3") inch diameter sleeve not sealed smoke-tight and 1" diameter copper pipe not sealed smoke-tight. Cummulatively these observed situations were not compliant with NFPA 101 (2000 ed.), section 18.3.6.3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

2. On 04/21/2015 at 3:43 pm, observation revealed on the 3rd floor in Smoke Compartment-3G, in the 3401C-Newborn Nursery Suite, Soiled Utility Room, that the corridor wall was not compliant. Duct tape was used to close the 6" diameter opening in the wall above the ceiling. The duct tape does not meet 'Limited-Combustible' requirements per NFPA 101 (2000 ed.), section 3.3.118 for a hospital. This room was not correctly identified in the Life Safety Plans. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.3.6.3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based on observation and interview, the facility did not provide corridor separation doors with doors with positive-latching hardware in the egress path. This deficiency occurred in 1 of the 74 smoke compartments within the hospital campus and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

5. On 08/06/2015 in the morning as part of a monitoring verification visit to the original survey from 4-20-2015 at 3:36 pm. It was continued to be observed in the 6B smoke compartment on the 6th floor, in the Corridor outside one of the Rooms, that the corridor cross-door would not positively self-latch when 5 pounds of pressure was applied to the door. This occurred without turning the latch and the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff KK (Power Plant Manager).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with doors with positive-latching hardware, sealed wall penetrations, fire-rated wall construction, and taped joints on fire-rated walls. These deficiencies occurred in 6 of the 74 smoke compartments in this hospital campus, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

7. On 04/21/2015 at 1:35 pm, observation revealed on the 3rd floor in the 3116E-South Wing Exit Stairs in Smoke Compartment-3D, that penetrations were not sealed according to an approved method. The deficiencies included two shut-off valves penetrating the 2-hour vertical fire rating. Could not verify the construction of shaft wall assembly. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

8. On 04/21/2015 at 3:05 pm, observation revealed on the 3rd floor in the 3428-Northwest Wing Stairwell in Smoke Compartment-3G, that a penetrations was not sealed according to an approved method. The deficiency included a three inch diameter sprinkler pipe penetration that was not fire-sealed to the required 2-hour rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

12. On 04/20/2015 at 1:50 pm, observation revealed on the 4th floor in the 4301-North Wing Suite in Smoke Compartment-4-I, that the shaft wall was not constructed to the required fire resistance rating because the construction joint was not sealed where the wall met the deck above. The upper corrugated metal decking was not properly fire caulked or fire sealed. Their was no intumescent fire material to stop the spread of smoke. The insulation stuffed between the metal deck and wall could not be verified it met all the requirements of a 2-hour shaft assembly against a 2-hour floor deck. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

13. On 04/21/2015 at 2:46 pm, observation revealed on the 3rd floor in the Corridor outside of North Stairwell 3311E of the North Wing at Smoke Compartment-3I, that the shaft wall was not constructed to the required fire resistance rating because the construction joint was not sealed where the wall met the deck above. Top-of-deck at shaft next to North Stairwell was not fire caulked and one conduit was not fire-caulked through 2-hour fire-rated assembly. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

14. On 04/21/2015 at 3:30 pm, observation revealed on the 3rd floor in the 3444-Corridor next to far Northwest Stairwell in Smoke Compartment-3H, that the enclosing wall was not constructed to a 2-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. Shaft wall above ceiling was not fully taped and screws mudded and penetrations fire-sealed per an approved assembly. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.

15. On 04/22/2015 at 9:53 am, observation revealed on the 3rd floor in the Electrical Closet #3548 in Smoke Compartment-3C, that the shaft wall was not constructed to the required fire resistance rating because the construction joint was not sealed where the wall met the deck above. This Pediatric Inpatient Sleeping Unit (3C) was recently remodeled and the top-of-wall at vertical shaft within the electrical room was not properly fire-sealed along with seams & penetrations. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with and compliant sized lettering on "no-exit" signs. This deficiency occurred in 1 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/22/2015 at 2:05 pm, observation revealed on the 2nd floor in the Corridor Number 2992, that the layout and lettering on the no exit sign did not meet the code requirements. The word NO and the word Exit were written in same line with the letters 2 inches high. The code requires the word NO in letters 2 inches high with stroke width of 3/8 inch and the word in letters 1 inch high, with the word EXIT below the word NO. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

2. On 04/22/2015 at 2:10 pm, observation revealed on the 2nd floor in the Room number 2993D, that the layout and lettering on the no exit sign did not meet the code requirements. The word NO and the word Exit were written in same line with the letters 2 inches high. The code requires the word NO in letters 2 inches high with stroke width of 3/8 inch and the word in letters 1 inch high, with the word EXIT below the word NO. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).


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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations and rated wall construction. This deficiency occurred in 14 of the 74 smoke compartments within the hospital campus, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/21/2015 at 9:40 am, observation revealed on the 5th floor in the Smoke Barrier wall above ceiling over cross corridor Smoke Barrier doors, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all the drywall screws were covered with drywall compound as required for designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

3. On 04/20/2015 at 3:39 pm, observation revealed on the 4th floor in the 4500-Corridor at Smoke Barrier SC-4D & 4E, that penetrations were not sealed according to an approved method. The deficiency included multiple penetrations of 1/2" & 3/4" sleeves not fire-sealed through the smoke barrier and a 36" diameter opening to the left of the fire extinguisher cabinet above the ceiling and parts of the top-of-deck to barrier wall were not properly fire-sealed to the requirements of this smoke barrier. A 24" x 12" patch was not properly fire-sealed. Cumulative penetrations along entire length of this smoke barrier (CS-4D & 4E) is a serious danger to life in a fire emergency. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

4. On 04/21/2015 at 3:10 pm, observation revealed on the 3rd floor in the Corridors 3320 & 3442 at Smoke Barrier between SC-3G & SC-3H, that penetrations were not sealed according to an approved method. The deficiency included multiple penetrations through the smoke barrier. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

5. On 04/21/2015 at 3:35 pm, observation revealed on the 3rd floor in the 3444-Corridor at smoke barrier in SC-3H & SC-3G, that penetrations were not sealed according to an approved method. The deficiency included 4" diameter sleeve, 1" diameter conduit, 2" diameter vent not properly sealed through a fire-rated smoke barrier. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

6. On 04/21/2015 at 3:45 pm, observation revealed on the 3rd floor in the 3558-Corridor at smoke barrier in SC-3G & SC-3E, that penetrations were not sealed according to an approved method. The deficiency included pneumatic tube not properly fire-sealed and a 3" diameter hole not properly fire-sealed. The 3" opening had paper stuffed in the opening. These are fire-rated wall assemblies. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

7. On 04/20/2015 at 10:40 am, observation revealed on the 4th floor in the 4601-East Corridor in SC-4B & 4A, that the smoke barrier wall was not constructed to either a 1-hr or 1/2-hour fire resistance rating because patches in the drywall were not properly coated with joint compound at metal screws and drywall joints were not properly sealed per the approved assembly used at time of construction. Some walls above the ceiling were observed with 'silicon' caulk at seams. This type of caulk could not be confirmed to be fire resistant. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

9. On 04/20/2015 at 10:55 am, observation revealed on the 4th floor in the 4649-Staff Room in Smoke Compartment-4B & Smoke Compartment-4A, referred to as Southwest Unit that the smoke barrier wall was not constructed to either a 1-hr or 1/2-hour fire resistance rating because patches in the drywall were not properly coated with joint compound at metal screws and drywall joints were not properly sealed per the approved assembly used at time of construction on the North side of the smoke barrier wall. Fire-bags were loosely installed in the cable tray hole and would not stop smoke through the smoke barrier hole. North side of smoke barrier wall, above the ceiling, was observed with 'silicon' caulk at unfinished seams on both sides of the wall barrier. This type of caulk could not be confirmed to be fire resistant. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

10. On 04/20/2015 at 11:00 am, observation revealed on the 4th floor in the 4601-West Corridor in SC-4B & 4A , that the smoke barrier wall was not constructed to either a 1-hr or 1/2-hour fire resistance rating because patches in the drywall were not properly coated with joint compound at metal screws and drywall joints were not properly sealed per the approved assembly used at time of construction. Some walls above the ceiling were observed with 'silicon' caulk at seams. This type of caulk could not be confirmed to be fire resistant. The discovery was above the ceiling tiles. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

11. On 04/20/2015 at 11:01 am, observation revealed on the 4th floor in the 4617, 4618, 4639 & 4640-Inpatient Sleeping Rooms in SC-4B & 4A, that the smoke barrier wall was not constructed to either a 1-hr or 1/2-hour fire resistance rating because patches in the drywall were not properly coated with joint compound at metal screws and drywall joints were not properly sealed per the approved assembly used at time of construction. Some walls above the ceiling were observed with 'silicon' caulk at seams. This type of caulk could not be confirmed to be fire resistant. Based on cumulative observations along this entire smoke barrier from outside wall to outside wall, these walls may not meet the minimum fire resistant requirements for a smoke barrier. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

12. On 04/21/2015 at 11:38 am, observation revealed on the 3rd floor in the Smoke Barrier between SC-3A & SC-3B, that the smoke barrier wall was not constructed to either a 1-hr or 1/2-hour fire resistance rating because patches in the drywall were not properly coated with joint compound at metal screws and drywall joints were not properly sealed per the approved assembly used at time of construction. The walls above the ceiling were observed with 'silicon' caulk at seams. This type of caulk could not be confirmed to be fire resistant. Based on cumulative observations along this entire smoke barrier from outside wall to outside wall, these walls may not meet the minimum fire resistant requirements for a smoke barrier. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

13. On 04/21/2015 at 11:39 am, observation revealed on the 3rd floor in the 3617, 3618, 3639 & 3640-Inpatient Sleeping Rooms in SC-3B & 3A, that the smoke barrier wall was not constructed to either a 1-hr or 1/2-hour fire resistance rating because patches in the drywall were not properly coated with joint compound at metal screws and drywall joints were not properly sealed per the approved assembly used at time of construction. Some walls above the ceiling were observed with 'silicon' caulk at seams. This type of caulk could not be confirmed to be fire resistant. Based on cumulative observations along this entire smoke barrier from outside wall to outside wall, these walls may not meet the minimum fire resistant requirements for a smoke barrier. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

14. On 04/21/2015 at 8:46 am, observation revealed on the 4th floor at Corridor 4536A in the Smoke Barrier between Smoke Compartment-4C & Smoke Compartment-4E, that the wall was not constructed to a 1-hour or 1/2 hour fire resistance rating because not all the drywall screws were covered with drywall compound as required for designs for rated walls. It was observed the seams were not taped in numerous locations. The data wire sleeves were filled up to 100%, without proper documentation, this type of penetration did not meet the approved assembly for this application. It must meet an approved assembly fire-rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

15. On 04/21/2015 at 9:27 am, observation revealed on the 4th floor in the 4536A-Corridor outside of Ultrasound Room #1 in SC-4E, that the enclosing wall was not constructed to a 1-hour or 1/2 hour fire resistance rating because not all of the drywall joints were taped, covered with drywall compound as required for designs for rated walls. Four pipes of 1" diameter were not properly fire sealed. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

19. On 04/22/2015 at 9:37 am, observation revealed on the 3rd floor in the West Wing Smoke Barrier between Smoke Compartment-3E & Smoke Compartment-3C, that penetrations were not sealed according to an approved method. The deficiencies included a sprinkler pipe and four 1/2" diameter conduits not properly fire-sealed through a fire-rated wall assembly and metal screws not double mudded. These observed situations were not compliant with NFPA 101 (2000 ed.), 18.3.7.3. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).

20. On 04/22/2015 at 9:10 am, observation revealed on the 3rd floor in the 3506E-Corridor at Smoke Barrier in SC-3C, that the smoke barrier wall was not constructed to a 1-hour or 1/2-hour fire resistance rating because the construction joints were not sealed where the wall met the deck above. Also observed multiple penetrations by sleeves, walls seams not taped, screws not double mudded, wires laying on ceiling grid from previous repairs. These observed situations were not compliant with NFPA 101 (2000 ed.), 18.3.7.3. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).

21. On 04/22/2015 at 10:15 am, observation revealed on the 3rd floor in the Corridor #3506D at Smoke Barrier between SC-3C & SC-3E , that the smoke barrier wall was not constructed to a 1-hour or 1/2-hour fire resistance rating because the construction joint was not sealed where the wall met the deck above. Also observed screws not mudded and one hole not fire-sealed. These observed situations were not compliant with NFPA 101 (2000 ed.), 18.3.7.3. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).
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29942

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with smoke-tight seals at meeting edges, and pairs of opposite-swinging cross-corridor doors. This deficiency occurred in 5 of the 74 smoke compartments within this hospital campus, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/21/2015 at 11:40 am, observation revealed on the 3rd floor in the 301D & 301E - Corridors, at smoke barrier doors in Smoke Compartment-3B & Smoke Compartment-3A, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. The corridor smoke barrier doors had attached vertical astragals that were non-compliant fire-rated astragals (combustible material). Documentation was not provided at time of survey to show they met the approved assembly or the door manufacturer fire tested requirements. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.6 and 8.3.4.

2. On 04/21/2015 at 1:46 pm, observation revealed on the 3rd floor in the 3231-Separation Wall Barrier between Bldg. #02 & Bldg. #01, that the pair of cross-corridor smoke barrier doors did not swing in opposite directions. These doors are both Separation Barrier doors and Smoke Barrier doors, requiring the double-egress swing in new construction. Surveyor was told these Pediatric spaces were renovated in 2012 meaning they must meet new construction. Life Safety Plans were showing double egress swinging doors on the plans, since these egress doors fall on the smoke barrier they must be double egress. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based on observation and interview, the facility did not enclose hazardous rooms with doors with positive-latching hardware and fire-seal walls with UL approved systems. These deficiencies occurred in 3 of the 74 smoke compartments, and had the potential to affect 19 of the 440 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

3. On 08/06/2015 as part of a monitoring verification visit from the original survey on 04/20/2015 at 10:33 am, observation revealed on the 4th floor in the Center Wing - Hazardous area 4209, that the hazardous area was not compliant. Several of the spaces holding materials considered hazardous, were not properly built to the required 1-hour fire protection requirement as per the revised and updated Life Safety Plan. This was compounded by some of the rooms also located on the Separation Wall barrier. Observed several spaces with penetrations not properly fire-sealed at hazardous spaces. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. These observed situations were not compliant with NFPA 101 (2000 ed.), 19.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager), staff LL (Director Project Mgmt.).

4. On 08/06/2015 as part of a monitoring verification visit from the original survey on 04/21/2015 at 1:55 pm, observation revealed on the 3rd floor in the 3207, 3203 & 3204-Hazardous Spaces at Center Wing in SC-3F, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. The walls were not properly completed to the required fire-rating for hazardous spaces, where seams are taped and mudded and screws double mudded per their UL assembly. Also found drywall patches were not properly taped and fire-sealed. Some of the patches were 18" x 18". The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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28616

Based on observation and interview, the facility did not enclose hazardous rooms with fire-rated doors, sealed wall penetrations, rated wall construction and taped joints on rated walls. This deficiency occurred in 8 of the 74 smoke compartments within this hospital campus, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/20/2015 at 3:07 pm, observation revealed on the 4th floor in the 4420-Cath Lab Core area in SC-4H, that the hazardous room was not compliant. In review of this Core Workroom space, with the amount of combustibles within the space from; linens, cath lab cassettes in storage, and other general storage items of a combustible nature, this space needs to be enclosed to a hazardous space requirement. The vision panels from Core Workroom area into the Cath Labs were not approved fire-rated doors. Surveyor was told the walls above the ceilings in this space were never fire-rated to a hazardous space requirement. We did not open any ceiling tiles in the Core Workroom area due to the multiple patient procedures occurring in the immediate surrounding area at time of survey. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

2. On 04/20/2015 at 3:17 pm, observation revealed on the 4th floor in the 4415-Trash Storage Room in SC-4H, that the hazardous room was not compliant. The room had the following items that would deem this room hazardous: 64 gal. storage cart, 32 gal. storage cart, 25 gal. storage cart. This room is not identified on the Life Safety Plans as being a hazardous space and therefore miss identified. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. The flex-ducts above the ceiling were not fire-dampered. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

3. On 04/20/2015 at 3:18 pm, observation revealed on the 4th floor in the 4413-Soiled Utility Room in SC-4H, that the hazardous room was not compliant. The room had numerous combustible items that deem this room hazardous. This room is not identified on the Life Safety Plans as being a hazardous space and therefore miss identified. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. The flex-ducts above the ceiling were not fire-dampered. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

4. On 04/21/2015 at 9:00 am, observation revealed on the 4th floor in the 4539B-Data Room in Smoke Compartment-4C, that the hazardous room was not compliant. The room had numerous combustible items that deem this room a hazardous space. This room is not identified on the Life Safety Plans as being a hazardous space, therefore miss identified. This space does not meet NFPA 101 (2000 ed.), Section 18.3.2.1. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

5. On 04/21/2015 at 2:49 pm, observation revealed on the 3rd floor in the 3307-Soiled Holding Room in SC-3I, that the hazardous room was not compliant. Room was not identified in the Life Safety Plan as a hazardous space per NFPA 101, Chapter 18 or 19 for soiled holding rooms. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

7. On 04/20/2015 at 3:11 pm, observation revealed on the 4th floor in the spaces #4417, #4418, #4419, #4423, #4424, #4425, #4426, #4427, #4428, #4429 and #4430 Room, doors to the Catherization Laboratory Core Workroom in Smoke Compartment-4H, the doors in the hazard enclosure walls could not be verified of having at least a 45 minute fire-rating. These observed situations were not compliant with NFPA 101 (2000 ed.), 18.3.2.1. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

12. On 04/21/2015 at 11:41 am, observation revealed on the 3rd floor in the 3650C-Clean Storage Room in Smoke Compartment-3A, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. This room was identified on the Life Safety Plans as a hazardous space and housed many combustible items. Screws were not mudded on a patch. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

13. On 04/21/2015 at 11:45 am, observation revealed on the 3rd floor in the 3601-Southwest Wing East Corridor in Smoke Compartment-3A, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. Fire-rated wall outside of Soiled Linen Chute Room and above ceiling, was not properly fire-sealed to a UL assembly. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

14. On 04/22/2015 at 11:03 am, observation revealed on the 2nd floor in the Storage Room #2605 in SC-2B, that the door would not positively self-latch when released because the closer could not pull it fully-closed. Also, screw heads were not mudded above the ceiling for recently remodeled space as new construction. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).

15. On 04/22/2015 at 9:31 am, observation revealed on the 3rd floor in the 3537, 3537A, 3538 & 3538A Hazardous Spaces of Clean Supplies and Soiled Utilities in SC-3C, that penetrations were not sealed according to an approved method. The deficiencies included multiple data metal sleeves and loose wires not fire-sealed through fire-rated wall assemblies. Room 3538A has a 8" x 8" hole and the space was not identified correctly in the Life Safety Plans and should have been. These observed situations were not compliant with NFPA 101 (2000 ed.), 18.3.2.1. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).

16. On 04/22/2015 at 10:05 am, observation revealed on the 3rd floor in the Pediatric Procedure Suite (2,669 SF) in SC-3C, that penetrations were not sealed according to an approved method. The deficiencies included two 1" diameter holes in Supply Room within this Suite. These observed situations were not compliant with NFPA 101 (2000 ed.), 18.3.2.1. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).

17. On 04/22/2015 at 10:10 am, observation revealed on the 3rd floor in the Pediatric Procedure Suite (2,669 SF) in SC-3C, that the wall of this hazardous room was not constructed to the required resistance rating because the construction joint was not sealed where the wall met the deck above. Partial wall missing above ceiling of Soiled Utility Room, required to be 1-hour fire-rated per Life Safety Code 101, Chapter 18. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).
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Based on observation and interview, the facility did not provide egress paths at all times with doors that swing in the direction of egress and door hardware that operated with a single release motion. These deficiencies occurred in 1 of the 74 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

5. On 04/21/2015 at 1:46 pm, observation revealed on the 3rd floor at the 3230 & 3231-Center Wing Corridors in SC-3F, that the door in the path of egress did not swing in the direction of egress travel. This Center Wing for Pediatrics was recently renovated in 2012. The Life Safety Plans (completed in January 2015) were incorrect on double doors at the corridor. Plans showed 3231 & 3230 as double egress doors, when in fact they were one-directional doors connecting to a continuous corridor on the other side of these doors at a 2-hour smoke barrier. These should have been double-egress doors for a new renovation project per NFPA 101, section 18.3.7.5. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.4.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).

6. On 04/21/2015 at 1:48 pm, observation revealed on the 3rd floor at the 3260 & 3261-Center Wing Corridors in SC-3F, that the door in the path of egress did not swing in the direction of egress travel. This Center Wing for Pediatrics was recently renovated in 2012. The Life Safety Plans (completed in January 2015) were incorrect on double doors at the corridors. Plans showed 3260 & 3261 as one-directional doors, when in fact they were double-egress doors connecting to a continuous corridor on the other side of these doors at a 2-hour smoke barrier. These should have been identified in the Life Safety Plans as double-egress doors for a new renovation project per NFPA 101, section 18.3.7.5. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.4.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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29942

Based on observation and interview, the facility did not provide egress paths at all times with egress without passing through intervening hazardous rooms. This deficiency occurred in 1 of the 74 smoke compartments within the hospital campus and had the potential to affect of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 04/21/2015 at 2:25 pm surveyor observed in the A1 smoke compartment on the Level A floor in the Conference Room, A618, that an intervening room in the means of egress was considered hazardous. Occupancy in the room exceeded 50 people. A second exit light led to an exit through a storage room. The light switch, in the storage room, was not near the exit travel. The second exit out of the space was less than 1/3 the distance diagonally (too close) to the corridor exit. Additionally, a movable screen was in the Storage Room doorway blocking egress. These collective observations were not compliant with NFPA 101 (2000 edition), 19.2.5.5. These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff II (V-P Operations), staff MM (Maintenance Mechanic) and staff KK (Power Plant Manager).
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Based on observation and interview, the facility did not provide and maintain corridor widths that were at least the minimal clear width required by the code. The proper width of corridors is 8'-0" fornew construction. This deficiency occurred in 1 of the 74 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 04/21/2015 at 1:49 pm, observation revealed on the 3rd floor in the 3260 & 3261-Center Wing Corridors in SC-3F, that the clear and unobstructed width of the corridor was less than 8'-0" for new construction or renovation. These corridors were observed to have bed traffic coming from the Elevator Lobby & the Pediatrics West Wing SC-3C/3E Inpatient Unit. 8'-0" wide Corridors were observed on the other side of the 2-hour smoke barrier & separation wall barrier. You cannot diminish the corridor width in a fire emergency. The double-egress requirement comes from NFPA 101, section 18.2.3.3, New Health Care Occupancies, to provide emergency patient movement in opposite directions in a fire emergency. This Center Wing Pediatrics area was renovated in 2012, as new. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3. Corridors used by patients are required to be at least 8'-0" wide. Corridors used only by others (staff) must be at least 44" wide. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with smoke detectors at required locations. This deficiency occurred in 1 of the 74 smoke compartments within the hospital campus, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/22/2015 at 9:34 am, observation revealed on the 3rd floor in the Corridor Alcove #3531 in Smoke Compartment-3C, that the smoke detector was not located in accordance with NFPA 72 requirements. The smoke detector was 'missing' in the alcove not monitored 24 hours a day & 7 days a week. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.6.1.4 and NFPA 72 (1999 ed.), 2-2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgm't.).
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32724

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 101 and NFPA 72 with compliant fire alarm notification. This deficiency occurred in 1 of the 74 smoke compartments within the hospital campus and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 04/21/2015 at 11:00 am, observation revealed on the 5th floor in the Women Locker Room #5516, that the fire alarm installation was not compliant. Audible and visible signal notifications were not provided to alert the occupants of fire and other emergencies. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.3.4.3.1 and 9.6.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).
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Based on observation and interview, the facility did not provide a ventilation system in accordance with the manufacturer specifications and NFPA 90A (1999 ed.) with missing fire dampers, and missing fire/smoke dampers in new construction. This deficiency occurred in 5 of the 74 smoke compartments within the hospital campus and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

2. Patient in room on verification visit 08/06/2015 and could not verify. Original survey on 04/21/2015 at 1:25 pm, observation revealed on the 3rd floor in the Separation Wall Barrier between the Hospital (I-2 Occupancy) and the Ronald McDonald House (R-2 Occupancy) at SC-3D, that a fire/smoke damper was not installed in an air-transfer duct that penetrated the 2-hour fire-rated wall assembly. This was new construction requiring a fire/smoke damper. The required 2-hour fire-rated separation barrier was missing the combination fire/smoke dampers on the HVAC system (supply and return ducting) for new construction at Separation Barrier. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2.1 and NFPA 90A (1999 ed.), 3-3.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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Based on interview, observations and a review of facility flame spread documents, the facility did not provide hanging drapes or show curtains that met code requirements, such as; flammability or sprinkler obstructions at both cubical curtains and shower curtains. Some do not permit the designed distribution of sprinkler water. These deficiencies occurred in 3 of the 74 smoke compartments within the hospital campus and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/21/2015 at 2:51 pm, observation revealed on the 5th floor in the Shower Room #5967, that a shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the other side of the shower curtain. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.5 and NFPA 13 (1999 ed.), 5-6.5.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

2. On 04/21/2015 at 3:35 pm, observation revealed on the 2nd floor in the Shower Room #2949, that a shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the other side of the shower curtain. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.5 and NFPA 13 (1999 ed.), 5-6.5.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

3. On 04/21/2015 at 3:51 pm, observation revealed on the 2nd floor in the Women Locker Room #2988-Shower area, that a shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the other side of the shower curtain. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.5 and NFPA 13 (1999 ed.), 5-6.5.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

4. On 04/20/2015 at 12:21 pm, observation revealed on the 4th floor in the 49B-Patient Toilet Room in SC-4J, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower stall. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.5 and NFPA 13 (1999 ed.), 5-6.5.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff LL (Director Project Mgmt.).
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29942

Based on interview and observation, the facility did not provide hanging drapes or curtains that met code requirements, such as sprinkler obstruction with cubical curtains that restrict the designed distribution of sprinkler water. This deficiency occurred in 2 of the 74 smoke compartments within the hospital campus and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 04/21/2015 at 9:00 am, observation revealed on the 5th floor in the Toilet Room #5614, that a shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the other side of the shower curtain. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.5 and NFPA 13 (1999 ed.), 5-6.5.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).

2. On 04/21/2015 at 9:30 am, observation revealed on the 5th floor in the Toilet Room #5632, that a shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the other side of the shower curtain. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.5 and NFPA 13 (1999 ed.), 5-6.5.2.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff JJ (Maintenance Manager) and staff PP (Lead Maintenance Mechanic).
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