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Based on random observation during the survey walk through, exit access is not accessible at all times to comply with 19.2.1. Designated egress doors were observed in the locked position. This condition may delay staff from gaining access to a means of egress during a fire event.

A. CORRECTED 01/09/14


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B. CORRECTED 01/09/14

C. On 02/01/13 the surveyor observed patient room doors which extended into the required 8 foot width of the corridor a minimum of 11inches on both sides of the corridor. This was observed for every patient room on the second floor corridor. An example location is room # 2200.

A fire alarm system with approved components, devices or equipment is not installed according to NFPA 72, National Fire Alarm Code, to provide effective warning and to direct staff to the source of the fire.

Findings include:

A. On 5/17/12 during the fire alarm tests locations were observed at the 2nd floor nurse station where the flash from more than two strobes are visible and not synchronized in accordance with NFPA 72, 1999, 4-4.4.2.3.


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B. CORRECTED 01/31/13.

The fire alarm system with approved components, devices or equipment is not installed according to NFPA 72, National Fire Alarm Code, to provide effective warning and to direct staff to the source of the fire.

Findings include:

A. CORRECTED 02/01/13

B. On 5/17/12 during the fire alarm tests locations were observed where more than 2 strobes are visible and not synchronized in accordance with NFPA 72, 1999, 4-4.4.2.3. Locations include:

1. Main - 8th floor
2. Main - 7th floor


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Based on random observation during the survey walk-through on May 15, 2012, not all portions of the building fire alarm system are maintained in accordance with 19.3.4 and NFPA 72.
Findings include:

C. CORRECTED 02/01/13

D. The strobes in the Kitchen were not syncronized to comply with NFPA 72-1999, 4-4.4.2.3.


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E. CORRECTED 02/01/13


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F. CORRECTED 01/07/15

A. CORRECTED 02/01/13
B. CORRECTED 02/01/13


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Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA 13-1999.
Findings include:

C. The 1st floor Data room 1423 had ceiling tile displaced and openings to chase areas not provided with sprinkler protection.

New 01/07/15: The non sprinklered chase space open to the Data Room is still not sprinklered protected and did not meet the completion date of 1/16/13 on the PoC.

D. CORRECTED 02/01/13


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E. CORRECTED 01/07/15.
F. CORRECTED 01/07/15.



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G. 1. CORRECTED 01/07/15.
2. CORRECTED 01/07/15.

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A 1999. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke and fire to pass between building stories.

Findings include:

A. At 11:15 AM on May 15, 2012, a duct was observed, which penetrates the floor in Fifth Floor Mechanical Room 5241, for which the fire damper is not in the plane of the floor as required by NFPA 90A 1999 3-3.2.

New 01/08/15: Based on direct observation while accompanied by the provider's representatives during the follow-up suvey, the duct which penetrates the Fifth Floor Mechanical Room 5241 located at the corner, and serves four (4) floors down is not installed in a continuous two hour fire rated ventilation shaft walls. Part of this ductwork was observed installed with a duct wrap protection on the Third Floor and on the 4th Floor which does not comply with the requirements of NFPA 90A 1999 3-3.4.1.

B. At 11:19 AM on May 15, 2012, the following conditions were observed relative to a duct which penetrates the 2 hour fire rated wall between Fifth Floor Mechanical Room 5241 and Corridor T5602:
1. The duct penetration was observed to lack a fire damper required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1.

2. The duct penetration was observed to not be sealed against the passage of fire in accordance with a tested design as required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1. because a large gap exists between the duct and the wall.

New 01/08/15: Based on direct observation while accompanied by the provider's representatives during the follow-up suvey, the duct which penetrates the Fifth Floor Mechanical Room 5241 located at the corner, and serves four (4) floors down is not installed in a continuous two hour fire rated ventilation shaft walls. Part of this ductwork was observed installed with a duct wrap protection on the Third Floor and on the 4th Floor which does not comply with the requirements of NFPA 90A 1999 3-3.4.1. Note that this is the same duct noted on Item A and B.



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C. CORRECTED 01/31/13

D. During the record review process it was discovered the facility did not have building ventilation drawings to show the location of fire and smoke dampers in accordance with 3-4.6.1.

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 to comply with 19.2.3.3. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

A. May 15th 2:15pm 4th floor, ICU Corridors contain numerous mobile nurse computer stations - located one between every second room. Each station contained one to two chairs located in front of them. The corridor exceeded 8 feet in width, however, the depth of the station alone exceeded the 7 inch distance of intrusion allowed by the life safety code.
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A. CORRECTED 02/01/13


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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.

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. CORRECTED 02/01/13
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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.
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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches. Examples include the elevator room panel EPA, (equipment branch?), serves all of the cab lighting that should be served from the life safety panel, and panel L1A a life safety panel serves the security camera and receptacles that should be fed from a critical panel. These examples and other locations throughout the building do not meet the requirements of NFPA-70, Section 517-31 thru 35.
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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches. In several locations the critical panels are serving exit signs, stairwell lighting, elevator lights, and med gas alarms that should be served from the life safety panels which does not meet the requirements of NFPA-70, Section 517-31 thru 35.
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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches. In several locations, life safety panels are serving items such as nurse's stations that should be served by the critical panel, and the critical panels are serving fire alarm and med gas panels that should be served from the life safety panels which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

New 01/07/15: The work to complete the Emergency power system throughout the Medical Center Complex to separate the life safety circuits, critical and equipment branch circuits did not meet the completion date of 11/30/14 noted on the PoC.




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B. CORRECTED 01/07/15

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches. In several locations, life safety panels are serving items such as nurse's stations that should be served by the critical panel, and the critical panels are serving fire alarm and med gas panels that should be served from the life safety panels which does not meet the requirements of NFPA-70, Section 517-31 thru 35.
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Based on random observation during the survey walk-through on the morning of May 16, 2012, not all portions of the facility's elevator penthouse installation are in accordance with NFPA 101 2000 and NFPA 13 1999. These deficiencies could cause injury to patients or staff while moving from floor to floor.

Findings include;

A. During the survey tour of the penthouse electronic elevator controllers were observed without provisions for the cooling of the controllers according to the manufacture's guidelines in accordance with NFPA 101 2000 9.4.5.

B. CORRECTED 01/31/13
Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

A. The surveyor did not find a single disconnect on elevator 30 and 31 for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.
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