HospitalInspections.org

Based on observation and interview it was revealed the facility failed to maintain fire rated barriers. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room 2700A second floor by boardroom, open unsealed penetrations of rated assembly.

Based on observation and interview it was revealed the facility failed to maintain the fire resistance rating of structural members. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room 7516 7C electrical room, spray-on fire proofing missing from structural steel members.

On 3/21/2013 - 4/4/2013, room 8516, spray-on fire proofing missing from structural steel members.

On 3/21/2013 - 4/4/2013, room 8601, spray-on fire proofing missing from structural steel members.

Based on observation and interview it was revealed the facility failed to ensure that the doors to the corridors are capable of resisting the passage of smoke. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room 8192 stem cell, door has a 1/2 inch gap along the side edge at the top.

On 3/21/2013 - 4/4/2013, room 4204 4E closet, door has a 1/4 inch gap along the meeting edge.

On 3/21/2013 - 4/4/2013, at pharmacy, doors will not close.

On 3/21/2013 - 4/4/2013, room 6016, doors will not close.

On 3/21/2013 - 4/4/2013, at entrance to dialysis by east elevator lobby, door will not close.

Based on observation and interview it was revealed the facility failed to maintain vertical rated assemblies. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, 7th floor elevator shaft wall 7 east, unsealed penetration in rated assembly.

On 3/21/2013 - 4/4/2013, 3rd floor east elevator shaft, unsealed penetration around toggle bolt penetrating rated assembly.

On 3/21/2013 - 4/4/2013, 1st floor elevator shaft #7, unsealed penetrations in rated assembly.

On 3/21/2013 - 4/4/2013, elevator shaft #23, unsealed penetrations in rated assembly between floors 8 and 7 and at 2m level.

On 3/21/2013 - 4/4/2013, room4789D HBE west FACP, horizontal fire rated door does not self-close and latch.

On 3/21/2013 - 4/4/2013, room6789D HBE FACP, horizontal fire rated door does not self-close and latch.

Based on observation and interview it was revealed the facility failed to maintain rated assemblies and the associated opening protectives. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, at cross corridor doors outside room 6628, smoke damper is not located in rated assembly. It appears a renovation project occured involving moving the rated assembly, but failed to move the smoke damper.

On 3/21/2013 - 4/4/2013, at cross corridor doors outside room 8628, unsealed penetrations where cable tray penetrates rated assembly.

On 3/21/2013 - 4/4/2013, room 4487D HBE FACP, ceiling tile missing.

On 3/21/2013 - 4/4/2013, 5201D communications closet, unsealed open conduit penetrating rated assembly.

On 3/21/2013 - 4/4/2013, corridor at entrance to west ICU, unsealed open penetration.

On 3/21/2013 - 4/4/2013, room 6487D FACP closet, ceiling tiles missing.

On 3/21/2013 - 4/4/2013, at cross corridor doors by room 5145, unsealed penetrations in rated assembly.

On 3/21/2013 - 4/4/2013, at cross corridor doors by room 5604, unsealed penetrations in rated assembly.

On 3/21/2013 - 4/4/2013, at cross corridor doors by room 5838, unsealed penetrations in rated assembly.

On 3/21/2013 - 4/4/2013, room G6530A, ceiling tiles missing.

On 3/21/2013 - 4/4/2013, above door to room 2007, unsealed penetrations in rated assembly.

On 3/21/2013 - 4/4/2013, at double doors in OR by stair #7, unsealed penetrations in rated assembly.

On 3/21/2013 - 4/4/2013, room 3603B, unsealed openings in ceiling tiles.

On 3/21/2013 - 4/4/2013, at cross corridor doors outside room 3090, unsealed penetrations where cable tray penetrates rated assembly.

On 3/21/2013 - 4/4/2013, corridor outside room 6871 , mobile equipment stored and being charged in the corridor.

On 3/21/2013 - 4/4/2013, outside 4299 at cross corridor doors leading to link, unsealed open penetration and rated assembly not continuous to deck above.

Based on observation and interview it was revealed the facility failed to maintain rated assemblies and the associated opening protectives. This violation has the potential to affect all occupants.

Survey findings include:
On 3/28/2013, at cross corridor doors outside room G230, unsealed penetrations in rated assembly.

Based on observation and interview it was revealed the facility failed to ensure that the self-closing smoke barrier doors were smoke resistant and with out a gap exceeding 1/8 of an inch at the meeting edges. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, outside 6628, cross corridor smoke partition doors have a gap in excess of 1/8 of an inch .

On 3/21/2013 - 4/4/2013, outside 8127, cross corridor smoke partition doors have a gap in excess of 1/8 of an inch .

On 3/21/2013 - 4/4/2013, outside 7127, cross corridor smoke partition doors have a gap in excess of 1/8 of an inch .

On 3/21/2013 - 4/4/2013, outside 7621, cross corridor smoke partition doors do not close.

On 3/21/2013 - 4/4/2013, outside 8105, cross corridor smoke partition doors do not close.

On 3/21/2013 - 4/4/2013, entrance to 6C on westside, cross corridor smoke partition doors have a gap in excess of 1/8 of an inch .

On 3/21/2013 - 4/4/2013, outside 5621, cross corridor smoke partition doors have a gap in excess of 1/8 of an inch .

Based on observation and interview it was revealed the facility failed to maintain the rated assembly enclosing hazardous areas. This violation has the potential to affect 4 smoke compartments.

Survey findings include:
On 3/21/2013 - 4/4/2013, 1095A soiled linens, open unsealed penetrations in rated assembly.

Based on observation and interview it was revealed the facility failed to maintain the rated assembly enclosing hazardous areas. This violation has the potential to affect 4 smoke compartments.

Survey findings include:
On 3/28/2013, 2158A electrical closet, open unsealed conduit penetrating rated assembly.

Based on observation and interview it was revealed the facility failed to ensure emergency lighting used to illuminate the means of egress is constantly ready. This violation has the potential to affect all occupants.

Survey findings include:
On 3/28/2013, room 2201 elevator machine room, battery operated emergency light fixture does not operate.

Based on observation and interview it was revealed the facility failed to maintain illuminated exit signs. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, 2mA near AHU 2M-26, exit sign chevron is indicating away from the means of egress.

On 3/21/2013 - 4/4/2013, cross corridor doors by 5174, exit light does not operate under emergency power supply.

Based on observation and interview it was revealed the facility failed to maintain the fire alarm system. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, at cafeteria entrance from main lobby, non-operational smoke detector from old system appears to be active.

On 3/21/2013 - 4/4/2013, stairway #3 at level 1, active smoke detector covered.

On 3/21/2013 - 4/4/2013, room 7509 E physican's on-call sleeping room, there is no local smoke detector located in this non-patient sleeping room.

On 3/21/2013 - 4/4/2013, room 4260 physican's on-call sleeping room, there is no local smoke detector located in this non-patient sleeping room.

On 3/21/2013 - 4/4/2013, pharmacy cage, the HVAC duct detector is not securely mounted.

On 3/21/2013 - 4/4/2013, room G021 new bustle electrical room, non-operational smoke detectors from old system appears to be active.

Based on observation and interview it was revealed the facility failed to maintain the fire alarm system. This violation has the potential to affect all occupants.

Survey findings include:
On 3/28/2013, room 2112A 2nd floor A storage, ceiling mounted smoke detector located within 12 inches of an HVAC air diffuser.

Based on observation and interview it was revealed the facility failed to maintain the sprinkler system. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, 2M exit to stair 5, sprinkler supply line secured with red wire to a threaded rod.

On 3/21/2013 - 4/4/2013, outside 1372-I, sprinkler heads spaced closer than 6 feet apart.

On 3/21/2013 - 4/4/2013, room 6485A, sprinkler head obstructed by material. There is not 18 inches of clear space.

On 3/21/2013 - 4/4/2013, outside room 3410 above ceiling, sprinkler supply line supported by electrial circuit wire.

On 3/21/2013 - 4/4/2013, main corridor by pharmacy, sprinler head painted with interior finish paint.

On 3/21/2013 - 4/4/2013, in corridor outside IR19 at scrub sink, storage on shelf above scrub sink within 18 inches of a sprinkler head. Sprinkler head spray pattern is obstructed.

Based on observation and interview it was revealed the facility failed to maintain the sprinkler system. This violation has the potential to affect all occupants.

Survey findings include:
On 3/28/2013, room 1030C sprinkler control room, spare sprinkler head box does not have adequate number and type of spare heads. There is not a minimum of two heads of each type.

Based on observation and interview it was revealed the facility failed to maintain hand held portable fire extinguishers. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room G203C, fire extinguisher missing seal that hold pull pin in place.

On 3/21/2013 - 4/4/2013, room 3072B, fire extinguisher missing seal that hold pull pin in place.

Based on observation and interview it was revealed the facility failed to maintain the fire rated assembly of trash chute/ shaft. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room 8902, trash chute door does not close and latch.

On 3/21/2013 - 4/4/2013, G851 soiled linen, unsealed open penetration around sprinkler line entering linen chute.

Based on observation and interview it was revealed the facility failed to maintain the means of egress free of obstructions. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, corridor outside wheel chair storage 0 east, three chairs and a walker stored.

On 3/21/2013 - 4/4/2013, corridor outside room 6871 , mobile equipment stored and being charged in the corridor.

On 3/21/2013 - 4/4/2013, corridor of 4C , mobile equipment stored and being charged in the corridor.

Based on observation and interview it was revealed the facility failed to ensure that all furnishings and decorations meet the requirements for flame spread and smoke development. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room 8214multipurpose, no documentation of certification for curtains.

Based on observation and interview it was revealed the facility failed to maintain compressed gas cyclinders in an approved manner. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room H 486 Helipad, compressed gas cyclinders not secured in an approved manner.

On 3/21/2013 - 4/4/2013, room 3617, compressed gas cyclinder not secured in an approved manner.

On 3/21/2013 - 4/4/2013, room G578A pharmacy storage, compressed gas cyclinders not secured in an approved manner.

Based on observation and interview it was revealed the facility failed to ensure that the electrical system, connected equipment and devices are maintained and the emergency plan is up to date. This violations has the potential to affect all occupants.

Survey findings include:
On 3/26/2013, visitors area, cube adaptor without circuit protecton.

On 3/26/2013, emergency evacuation diagram is not concurrent with exit sign placement.

Based on observation and interview it was revealed the facility failed to ensure that the electrical system, connected equipment and devices are maintained. This violations has the potential to affect all occupants.

Survey findings include:
On 3/27/2013, kitchen office, electrical panel has unprotected openings where breakers are located.

On 3/27/2013, kitchen office at coffee bar, cube adaptor that does not have approved or listed circuit protection.

Based on observation and interview it was revealed the facility failed to maintain compressed gas cyclinders in an approved manner. This violation has the potential to affect all occupants.

Survey findings include:
On 3/26/2013, room 1021 oxygen storage, compressed gas cyclinders not secured in an approved manner.

Based on observation and interview it was revealed the facility failed to maintain electrical equipment; maintain rated assemblies; maintain the sprinkler system; and maintain the means of egress free of obstructions. These violations have the potential to affect all occupants.

Survey findings include:
On 3/28/2012, fire alarm panel room across from room 1174, exposed temporary wiring.

On 3/28, 2013, room 1160 communications closet, open electrical junction boxes with exposed wires.

On 3/28/2013, room G334 mechanical pump room, open electrical LB box and junction box with exposed wires.

On 3/28/2013, room 2260 electrical room, unsealed conduit penetrating rated assembly.

On 3/28/2013, fire alarm panel room across from room 1174, unsealed penetrations of rated assembly.

On 3/28/2013, behind room P002, spray-on fire proofing missing from structural member.

On 3/28/2013, room 3341 electrical, spray-on fire proofing missing from structural member.

On 3/28/2013, room 3317 above rated door, unsealed conduit penetrating rated assembly.

On 3/28/2013, room 3341 electrical, unsealed sprinkler pipe sleeve penetrating rated assembly.

On 3/28/2013, G265 tomotheraph computer room, sprinkler head escutcheon plate missing.

On 3/28/2013, 2310 corridor, portable computer cart (WOW) housed in means of egress. Unit was attached to an electrical wall outlet.

Based on observation and interview it was revealed the facility failed to maintain rated assembly opening protectives for the passage of smoke and/or fire, rated assemblies to resist smoke and/or fire, sprinkler system, electrical system, and means of egress free of impediments. These violations have the potential to affect all occupants.

Survey findings include:
On 3/29/2013, stair #3 at third level, rated door will not close and latch.

On 3/29/2013, third level in corridor outside child support services, rated wall not labeled above ceiling.

On 3/29/2013, outside suite 302, open unsealed penetrations of rated assembly.

On 3/29/2013, cross corridor door at 3308, from the marked egress side of this door there is locking arrangements that prevent free egress. Only persons with knowledge of an access code can freely egress. Staff disabled device immediately.

On 3/29/2013, room 2265 peds waiting area, sprinkler coverage inadequate. Obstructed by light fixture in the center of the ceiling.

On 3/29/2013, room 225 communications closet, there is no access to fire damper in duct work that penetrates rated assembly.

On 3/29/2013, main boiler room, needs signage from corridor that indicates mechanical room.

On 3/29/2013, new stairway at level G, there is combustible storage under stairs.

On 3/29/2013, on G level at multiple locations, ceiling tiles missing.

On 3/29/2013, sprinkler control valve room, the number of spare sprinkler heads are below the required minimum of six.

On 3/29/2013, cardiology waiting, hanging clouds obstruct sprinkler spray pattern and subsequent floor coverage.

On 3/29/2013, room 210 cardiology electrical, open junction box with exposed wires.

On 3/29/2013, cross corridor door across from room 215, marked means of egress door with thumb latch locking device.

On 3/29/2013, cross corridor door at staff entrance to cardiology, marked means of egress door with thumb latch locking device.

On 3/29/2013, room 225 patient waiting area, electrical conduit laying on top of sprinkler pipe.

On 3/29/2013, exterior, post indicating valve (PIV) tamper switch assembly and connected conduit is not secure or mechanically protected.

Based on observation and interview it was revealed the facility failed to maintain storage of materials in a neat and orderly manner. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, 0 East computer room, materials not stored in a neat and orderly manner. No aisles or access to all portions of the room.

Based on observation and interview it was revealed the facility failed to maintain the rated assembly enclosing hazardous areas and ensure fire rated assemblies are fire and smoke resistant. This violation has the potential to affect 4 smoke compartments.

Survey findings include:
On 3/26/2013, 21036 medical records, high density combustible material storage without a door.

On 3/26/2013, 51220 elevator equipment room, open unsealed penetration in rated assembly.

Based on observation and interview it was revealed the facility failed to maintain the sprinkler system and the electrical system. This violation has the potential to affect all occupants.

Survey findings include:
On 3/226/2013, 3203 corridor, sprinkler head spacing less than 6 feet.

On 3/26/2013, 1013 stairway, sprinkler head under stairs has paint other than approved by the manufacturer.

On 3/26/2013, room1117 behind workstation, extension cords in-us as permanent wiring.

On 3/26/2013, room 3040 administrative office under counter, recepticle is missing cover plate.

Based on observation and interview it was revealed the facility failed to ensure that flammable and combustible liquids are stored properly.This violation has the potential to affect 4 smoke compartments.

Survey findings include:
On 3/21/2013 - 4/4/2013, room G578A pharmacy storage, flammable liquids stored in corrosives locker. The chemicals are not compatable.

Based on observation and interview it was revealed the facility failed to ensure that the electrical system, connected equipment and devices are maintained. This violations has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room 4160 4E ICU, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6310, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6133, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 4149 4C, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6102, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6105, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6109, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6110, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 4183 4W, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 4152 4C, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 4156 4C, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, all HBE communications closets, open junction boxes with exposed wires.

On 3/21/2013 - 4/4/2013, all HBE FACP closets, open junction boxes with exposed electrical wires and fire alarm circut wires.

On 3/21/2013 - 4/4/2013, room 6126, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6129, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, at cross corridors by room 5193, open junction box with exposed wires.

On 3/21/2013 - 4/4/2013, room 5806 dayroom, power tap devices connected together and not directly into wall outlet.

On 3/21/2013 - 4/4/2013, room 3132, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 3136, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6871 communication closet, open junction box with exposed wires.

On 3/21/2013 - 4/4/2013, room 3102 3E, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 3117 dialysis, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 3125, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 3126, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 3130, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room G143, cover missing on bus duct.

On 3/21/2013 - 4/4/2013, room G203, open junction box above ceiling.

On 3/21/2013 - 4/4/2013, room G831 soiled utility, fire alarm panel has an unsealed opening.

On 3/21/2013 - 4/4/2013, room 4064, power tap devices connected together and not directly into wall outlet.

On 3/21/2013 - 4/4/2013, room 3063, power tap devices connected together and not directly into wall outlet.

On 3/21/2013 - 4/4/2013, room 3020, power tap devices connected together and not directly into wall outlet.

On 3/21/2013 - 4/4/2013, room 3025, power tap devices connected together and not directly into wall outlet.

On 3/21/2013 - 4/4/2013, room 3010, extension cord in-use as permanent wiring.

On 3/21/2013 - 4/4/2013, room 3020, extension cord in-use as permanent wiring.

On 3/21/2013 - 4/4/2013, room 3025, extension cord in-use as permanent wiring.

On 3/21/2013 - 4/4/2013, room 3020, multi-plug adaptor without approved and listed circuit protection.

On 3/21/2013 - 4/4/2013, nurses station across from 1060G, extension cord in-use as permanent wiring.

On 3/21/2013 - 4/4/2013, room 4011 records room, emergency light fixture power cord ran through ceiling and connected to an outlet.

Based on observation and interview it was revealed the facility failed to ensure that the electrical system, connected equipment and devices are maintained. This violations has the potential to affect all occupants.

Survey findings include:
On 3/28/2013, room 1081 electrical, breaker are not numbered to coincide with panel directory.

On 3/28/2013, room 1005 vending, extension cord in-use as permanent wiring.

Based on observation and interview it was revealed the facility failed to ensure that the installation of alchohol based hand rub (ABHR) dispensers are separated from combustible materials. This violation has the potential to affect 4 smoke compartments.

Survey findings include:
On 3/21/2013 - 4/4/2013, 3151 3C, linen cart with combustible materials stored under ABHR.

On 3/21/2013 - 4/4/2013, room 3179 patient room 3W, linen cart with combustible materials stored under ABHR.

Based on observation and interview it was revealed the facility failed to maintain fire rated barriers. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room 2700A second floor by boardroom, open unsealed penetrations of rated assembly.

Based on observation and interview it was revealed the facility failed to maintain the fire resistance rating of structural members. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room 7516 7C electrical room, spray-on fire proofing missing from structural steel members.

On 3/21/2013 - 4/4/2013, room 8516, spray-on fire proofing missing from structural steel members.

On 3/21/2013 - 4/4/2013, room 8601, spray-on fire proofing missing from structural steel members.

Based on observation and interview it was revealed the facility failed to ensure that the doors to the corridors are capable of resisting the passage of smoke. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room 8192 stem cell, door has a 1/2 inch gap along the side edge at the top.

On 3/21/2013 - 4/4/2013, room 4204 4E closet, door has a 1/4 inch gap along the meeting edge.

On 3/21/2013 - 4/4/2013, at pharmacy, doors will not close.

On 3/21/2013 - 4/4/2013, room 6016, doors will not close.

On 3/21/2013 - 4/4/2013, at entrance to dialysis by east elevator lobby, door will not close.

Based on observation and interview it was revealed the facility failed to maintain vertical rated assemblies. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, 7th floor elevator shaft wall 7 east, unsealed penetration in rated assembly.

On 3/21/2013 - 4/4/2013, 3rd floor east elevator shaft, unsealed penetration around toggle bolt penetrating rated assembly.

On 3/21/2013 - 4/4/2013, 1st floor elevator shaft #7, unsealed penetrations in rated assembly.

On 3/21/2013 - 4/4/2013, elevator shaft #23, unsealed penetrations in rated assembly between floors 8 and 7 and at 2m level.

On 3/21/2013 - 4/4/2013, room4789D HBE west FACP, horizontal fire rated door does not self-close and latch.

On 3/21/2013 - 4/4/2013, room6789D HBE FACP, horizontal fire rated door does not self-close and latch.

Based on observation and interview it was revealed the facility failed to maintain rated assemblies and the associated opening protectives. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, at cross corridor doors outside room 6628, smoke damper is not located in rated assembly. It appears a renovation project occured involving moving the rated assembly, but failed to move the smoke damper.

On 3/21/2013 - 4/4/2013, at cross corridor doors outside room 8628, unsealed penetrations where cable tray penetrates rated assembly.

On 3/21/2013 - 4/4/2013, room 4487D HBE FACP, ceiling tile missing.

On 3/21/2013 - 4/4/2013, 5201D communications closet, unsealed open conduit penetrating rated assembly.

On 3/21/2013 - 4/4/2013, corridor at entrance to west ICU, unsealed open penetration.

On 3/21/2013 - 4/4/2013, room 6487D FACP closet, ceiling tiles missing.

On 3/21/2013 - 4/4/2013, at cross corridor doors by room 5145, unsealed penetrations in rated assembly.

On 3/21/2013 - 4/4/2013, at cross corridor doors by room 5604, unsealed penetrations in rated assembly.

On 3/21/2013 - 4/4/2013, at cross corridor doors by room 5838, unsealed penetrations in rated assembly.

On 3/21/2013 - 4/4/2013, room G6530A, ceiling tiles missing.

On 3/21/2013 - 4/4/2013, above door to room 2007, unsealed penetrations in rated assembly.

On 3/21/2013 - 4/4/2013, at double doors in OR by stair #7, unsealed penetrations in rated assembly.

On 3/21/2013 - 4/4/2013, room 3603B, unsealed openings in ceiling tiles.

On 3/21/2013 - 4/4/2013, at cross corridor doors outside room 3090, unsealed penetrations where cable tray penetrates rated assembly.

On 3/21/2013 - 4/4/2013, corridor outside room 6871 , mobile equipment stored and being charged in the corridor.

On 3/21/2013 - 4/4/2013, outside 4299 at cross corridor doors leading to link, unsealed open penetration and rated assembly not continuous to deck above.

Based on observation and interview it was revealed the facility failed to maintain rated assemblies and the associated opening protectives. This violation has the potential to affect all occupants.

Survey findings include:
On 3/28/2013, at cross corridor doors outside room G230, unsealed penetrations in rated assembly.

Based on observation and interview it was revealed the facility failed to ensure that the self-closing smoke barrier doors were smoke resistant and with out a gap exceeding 1/8 of an inch at the meeting edges. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, outside 6628, cross corridor smoke partition doors have a gap in excess of 1/8 of an inch .

On 3/21/2013 - 4/4/2013, outside 8127, cross corridor smoke partition doors have a gap in excess of 1/8 of an inch .

On 3/21/2013 - 4/4/2013, outside 7127, cross corridor smoke partition doors have a gap in excess of 1/8 of an inch .

On 3/21/2013 - 4/4/2013, outside 7621, cross corridor smoke partition doors do not close.

On 3/21/2013 - 4/4/2013, outside 8105, cross corridor smoke partition doors do not close.

On 3/21/2013 - 4/4/2013, entrance to 6C on westside, cross corridor smoke partition doors have a gap in excess of 1/8 of an inch .

On 3/21/2013 - 4/4/2013, outside 5621, cross corridor smoke partition doors have a gap in excess of 1/8 of an inch .

Based on observation and interview it was revealed the facility failed to maintain the rated assembly enclosing hazardous areas. This violation has the potential to affect 4 smoke compartments.

Survey findings include:
On 3/21/2013 - 4/4/2013, 1095A soiled linens, open unsealed penetrations in rated assembly.

Based on observation and interview it was revealed the facility failed to maintain the rated assembly enclosing hazardous areas. This violation has the potential to affect 4 smoke compartments.

Survey findings include:
On 3/28/2013, 2158A electrical closet, open unsealed conduit penetrating rated assembly.

Based on observation and interview it was revealed the facility failed to ensure emergency lighting used to illuminate the means of egress is constantly ready. This violation has the potential to affect all occupants.

Survey findings include:
On 3/28/2013, room 2201 elevator machine room, battery operated emergency light fixture does not operate.

Based on observation and interview it was revealed the facility failed to maintain illuminated exit signs. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, 2mA near AHU 2M-26, exit sign chevron is indicating away from the means of egress.

On 3/21/2013 - 4/4/2013, cross corridor doors by 5174, exit light does not operate under emergency power supply.

Based on observation and interview it was revealed the facility failed to maintain the fire alarm system. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, at cafeteria entrance from main lobby, non-operational smoke detector from old system appears to be active.

On 3/21/2013 - 4/4/2013, stairway #3 at level 1, active smoke detector covered.

On 3/21/2013 - 4/4/2013, room 7509 E physican's on-call sleeping room, there is no local smoke detector located in this non-patient sleeping room.

On 3/21/2013 - 4/4/2013, room 4260 physican's on-call sleeping room, there is no local smoke detector located in this non-patient sleeping room.

On 3/21/2013 - 4/4/2013, pharmacy cage, the HVAC duct detector is not securely mounted.

On 3/21/2013 - 4/4/2013, room G021 new bustle electrical room, non-operational smoke detectors from old system appears to be active.

Based on observation and interview it was revealed the facility failed to maintain the fire alarm system. This violation has the potential to affect all occupants.

Survey findings include:
On 3/28/2013, room 2112A 2nd floor A storage, ceiling mounted smoke detector located within 12 inches of an HVAC air diffuser.

Based on observation and interview it was revealed the facility failed to maintain the sprinkler system. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, 2M exit to stair 5, sprinkler supply line secured with red wire to a threaded rod.

On 3/21/2013 - 4/4/2013, outside 1372-I, sprinkler heads spaced closer than 6 feet apart.

On 3/21/2013 - 4/4/2013, room 6485A, sprinkler head obstructed by material. There is not 18 inches of clear space.

On 3/21/2013 - 4/4/2013, outside room 3410 above ceiling, sprinkler supply line supported by electrial circuit wire.

On 3/21/2013 - 4/4/2013, main corridor by pharmacy, sprinler head painted with interior finish paint.

On 3/21/2013 - 4/4/2013, in corridor outside IR19 at scrub sink, storage on shelf above scrub sink within 18 inches of a sprinkler head. Sprinkler head spray pattern is obstructed.

Based on observation and interview it was revealed the facility failed to maintain the sprinkler system. This violation has the potential to affect all occupants.

Survey findings include:
On 3/28/2013, room 1030C sprinkler control room, spare sprinkler head box does not have adequate number and type of spare heads. There is not a minimum of two heads of each type.

Based on observation and interview it was revealed the facility failed to maintain hand held portable fire extinguishers. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room G203C, fire extinguisher missing seal that hold pull pin in place.

On 3/21/2013 - 4/4/2013, room 3072B, fire extinguisher missing seal that hold pull pin in place.

Based on observation and interview it was revealed the facility failed to maintain the fire rated assembly of trash chute/ shaft. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room 8902, trash chute door does not close and latch.

On 3/21/2013 - 4/4/2013, G851 soiled linen, unsealed open penetration around sprinkler line entering linen chute.

Based on observation and interview it was revealed the facility failed to maintain the means of egress free of obstructions. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, corridor outside wheel chair storage 0 east, three chairs and a walker stored.

On 3/21/2013 - 4/4/2013, corridor outside room 6871 , mobile equipment stored and being charged in the corridor.

On 3/21/2013 - 4/4/2013, corridor of 4C , mobile equipment stored and being charged in the corridor.

Based on observation and interview it was revealed the facility failed to ensure that all furnishings and decorations meet the requirements for flame spread and smoke development. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room 8214multipurpose, no documentation of certification for curtains.

Based on observation and interview it was revealed the facility failed to maintain compressed gas cyclinders in an approved manner. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room H 486 Helipad, compressed gas cyclinders not secured in an approved manner.

On 3/21/2013 - 4/4/2013, room 3617, compressed gas cyclinder not secured in an approved manner.

On 3/21/2013 - 4/4/2013, room G578A pharmacy storage, compressed gas cyclinders not secured in an approved manner.

Based on observation and interview it was revealed the facility failed to ensure that the electrical system, connected equipment and devices are maintained and the emergency plan is up to date. This violations has the potential to affect all occupants.

Survey findings include:
On 3/26/2013, visitors area, cube adaptor without circuit protecton.

On 3/26/2013, emergency evacuation diagram is not concurrent with exit sign placement.

Based on observation and interview it was revealed the facility failed to ensure that the electrical system, connected equipment and devices are maintained. This violations has the potential to affect all occupants.

Survey findings include:
On 3/27/2013, kitchen office, electrical panel has unprotected openings where breakers are located.

On 3/27/2013, kitchen office at coffee bar, cube adaptor that does not have approved or listed circuit protection.

Based on observation and interview it was revealed the facility failed to maintain compressed gas cyclinders in an approved manner. This violation has the potential to affect all occupants.

Survey findings include:
On 3/26/2013, room 1021 oxygen storage, compressed gas cyclinders not secured in an approved manner.

Based on observation and interview it was revealed the facility failed to maintain electrical equipment; maintain rated assemblies; maintain the sprinkler system; and maintain the means of egress free of obstructions. These violations have the potential to affect all occupants.

Survey findings include:
On 3/28/2012, fire alarm panel room across from room 1174, exposed temporary wiring.

On 3/28, 2013, room 1160 communications closet, open electrical junction boxes with exposed wires.

On 3/28/2013, room G334 mechanical pump room, open electrical LB box and junction box with exposed wires.

On 3/28/2013, room 2260 electrical room, unsealed conduit penetrating rated assembly.

On 3/28/2013, fire alarm panel room across from room 1174, unsealed penetrations of rated assembly.

On 3/28/2013, behind room P002, spray-on fire proofing missing from structural member.

On 3/28/2013, room 3341 electrical, spray-on fire proofing missing from structural member.

On 3/28/2013, room 3317 above rated door, unsealed conduit penetrating rated assembly.

On 3/28/2013, room 3341 electrical, unsealed sprinkler pipe sleeve penetrating rated assembly.

On 3/28/2013, G265 tomotheraph computer room, sprinkler head escutcheon plate missing.

On 3/28/2013, 2310 corridor, portable computer cart (WOW) housed in means of egress. Unit was attached to an electrical wall outlet.

Based on observation and interview it was revealed the facility failed to maintain rated assembly opening protectives for the passage of smoke and/or fire, rated assemblies to resist smoke and/or fire, sprinkler system, electrical system, and means of egress free of impediments. These violations have the potential to affect all occupants.

Survey findings include:
On 3/29/2013, stair #3 at third level, rated door will not close and latch.

On 3/29/2013, third level in corridor outside child support services, rated wall not labeled above ceiling.

On 3/29/2013, outside suite 302, open unsealed penetrations of rated assembly.

On 3/29/2013, cross corridor door at 3308, from the marked egress side of this door there is locking arrangements that prevent free egress. Only persons with knowledge of an access code can freely egress. Staff disabled device immediately.

On 3/29/2013, room 2265 peds waiting area, sprinkler coverage inadequate. Obstructed by light fixture in the center of the ceiling.

On 3/29/2013, room 225 communications closet, there is no access to fire damper in duct work that penetrates rated assembly.

On 3/29/2013, main boiler room, needs signage from corridor that indicates mechanical room.

On 3/29/2013, new stairway at level G, there is combustible storage under stairs.

On 3/29/2013, on G level at multiple locations, ceiling tiles missing.

On 3/29/2013, sprinkler control valve room, the number of spare sprinkler heads are below the required minimum of six.

On 3/29/2013, cardiology waiting, hanging clouds obstruct sprinkler spray pattern and subsequent floor coverage.

On 3/29/2013, room 210 cardiology electrical, open junction box with exposed wires.

On 3/29/2013, cross corridor door across from room 215, marked means of egress door with thumb latch locking device.

On 3/29/2013, cross corridor door at staff entrance to cardiology, marked means of egress door with thumb latch locking device.

On 3/29/2013, room 225 patient waiting area, electrical conduit laying on top of sprinkler pipe.

On 3/29/2013, exterior, post indicating valve (PIV) tamper switch assembly and connected conduit is not secure or mechanically protected.

Based on observation and interview it was revealed the facility failed to maintain storage of materials in a neat and orderly manner. This violation has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, 0 East computer room, materials not stored in a neat and orderly manner. No aisles or access to all portions of the room.

Based on observation and interview it was revealed the facility failed to maintain the rated assembly enclosing hazardous areas and ensure fire rated assemblies are fire and smoke resistant. This violation has the potential to affect 4 smoke compartments.

Survey findings include:
On 3/26/2013, 21036 medical records, high density combustible material storage without a door.

On 3/26/2013, 51220 elevator equipment room, open unsealed penetration in rated assembly.

Based on observation and interview it was revealed the facility failed to maintain the sprinkler system and the electrical system. This violation has the potential to affect all occupants.

Survey findings include:
On 3/226/2013, 3203 corridor, sprinkler head spacing less than 6 feet.

On 3/26/2013, 1013 stairway, sprinkler head under stairs has paint other than approved by the manufacturer.

On 3/26/2013, room1117 behind workstation, extension cords in-us as permanent wiring.

On 3/26/2013, room 3040 administrative office under counter, recepticle is missing cover plate.

Based on observation and interview it was revealed the facility failed to ensure that flammable and combustible liquids are stored properly.This violation has the potential to affect 4 smoke compartments.

Survey findings include:
On 3/21/2013 - 4/4/2013, room G578A pharmacy storage, flammable liquids stored in corrosives locker. The chemicals are not compatable.

Based on observation and interview it was revealed the facility failed to ensure that the electrical system, connected equipment and devices are maintained. This violations has the potential to affect all occupants.

Survey findings include:
On 3/21/2013 - 4/4/2013, room 4160 4E ICU, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6310, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6133, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 4149 4C, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6102, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6105, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6109, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6110, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 4183 4W, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 4152 4C, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 4156 4C, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, all HBE communications closets, open junction boxes with exposed wires.

On 3/21/2013 - 4/4/2013, all HBE FACP closets, open junction boxes with exposed electrical wires and fire alarm circut wires.

On 3/21/2013 - 4/4/2013, room 6126, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6129, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, at cross corridors by room 5193, open junction box with exposed wires.

On 3/21/2013 - 4/4/2013, room 5806 dayroom, power tap devices connected together and not directly into wall outlet.

On 3/21/2013 - 4/4/2013, room 3132, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 3136, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 6871 communication closet, open junction box with exposed wires.

On 3/21/2013 - 4/4/2013, room 3102 3E, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 3117 dialysis, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 3125, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 3126, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room 3130, power cord for accessory patient care equipment layed across the floor under the patient bed that has wheels.

On 3/21/2013 - 4/4/2013, room G143, cover missing on bus duct.

On 3/21/2013 - 4/4/2013, room G203, open junction box above ceiling.

On 3/21/2013 - 4/4/2013, room G831 soiled utility, fire alarm panel has an unsealed opening.

On 3/21/2013 - 4/4/2013, room 4064, power tap devices connected together and not directly into wall outlet.

On 3/21/2013 - 4/4/2013, room 3063, power tap devices connected together and not directly into wall outlet.

On 3/21/2013 - 4/4/2013, room 3020, power tap devices connected together and not directly into wall outlet.

On 3/21/2013 - 4/4/2013, room 3025, power tap devices connected together and not directly into wall outlet.

On 3/21/2013 - 4/4/2013, room 3010, extension cord in-use as permanent wiring.

On 3/21/2013 - 4/4/2013, room 3020, extension cord in-use as permanent wiring.

On 3/21/2013 - 4/4/2013, room 3025, extension cord in-use as permanent wiring.

On 3/21/2013 - 4/4/2013, room 3020, multi-plug adaptor without approved and listed circuit protection.

On 3/21/2013 - 4/4/2013, nurses station across from 1060G, extension cord in-use as permanent wiring.

On 3/21/2013 - 4/4/2013, room 4011 records room, emergency light fixture power cord ran through ceiling and connected to an outlet.

Based on observation and interview it was revealed the facility failed to ensure that the electrical system, connected equipment and devices are maintained. This violations has the potential to affect all occupants.

Survey findings include:
On 3/28/2013, room 1081 electrical, breaker are not numbered to coincide with panel directory.

On 3/28/2013, room 1005 vending, extension cord in-use as permanent wiring.