HospitalInspections.org

Based on observations, the facility failed to maintain the building construction.

The findings included:

Observations on 11/04/2019 between 11:20 AM - 3:14 PM, revealed the ceilings throughout the facility were not according to the buildings plans. Tiles throughout the facility have been altered and changed, not maintaining a 1 hour barrier.
NFPA 101, 19.1.6.1 (2012 Edition) NFPA 101, 8.2.3 (2012 Edition)

The VP of operations and maintenance director were present when this deficiency was identified, and was later acknowledged during the exit conference on 11/04/2019.

Based on observations, the facility failed to maintain the stairways.

The findings included:

1. Observations on 11/04/2019 at 11:20 AM, revealed the following deficiencies above the ceiling outside of the 3rd floor stair b on the rated fire/smoke barrier wall:
a. Steel joists not sealed
b. Grout falling between the concrete
c. 1 ½ inch conduit with the fire stop falling through
NFPA 101, 8.3.5.1 (2012 Edition)

2. Observations on 11/04/2019 at 12:23 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, outside of the stairwell shaft by room 21:
a. ½ conduit and ¼ flex in the same penetration not properly sealed
b. Left side bottom of beam is unsealed
c. Right side of beam not sealed properly (fire stop is falling out)
NFPA 101, 8.3.5.1 (2012 Edition)

3. Observations on 11/04/2019 at 12:27 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, inside of the stairwell shaft by room 21:
a. Unsealed at the deck
b. Steel trusses not properly sealed
NFPA 101, 8.3.5.1 (2012 Edition)

4. Observations on 11/04/2019 at 12:32 PM, revealed the following deficiencies above the ceiling on the rated masonry fire/smoke barrier, outside of the stairwell by registration (on the 2nd floor):
a. 10 x 4 inch improper sheetrock repair on the L side of beam
b. ½ inch copper lines unsealed
c. Steel trusses unsealed in the middle
NFPA 101, 8.3.5.1 (2012 Edition)

5. Observations on 11/04/2019 at 1:04 PM, revealed the bottom right side of a beam unsealed outside of the stairs by the admin office above the ceiling, on the rated fire/smoke barrier wall.
NFPA 101, 8.3.5.1 (2012 Edition)

The VP of operations and maintenance were present when these deficiencies were identified, and were later acknowledged during the exit conference on 11/04/2019.

Based on observations, the facility failed to maintain the hazardous areas.

The finding included:

Observations on 11/04/2019 at 1:42 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier wall outside of the facility engineer/powerhouse room:
a. Joint tape peeling at the deck
b. Trusses not sealed
c. Mixed fire stop around 3 inch metal sleeve with a copper line
NFPA 101, 8.3.5.1 (2012 Edition)

The VP of operations and maintenance were present when these deficiencies were identified, and were later acknowledged during the exit conference on 11/04/2019.

Based on observations, the facility failed to maintain the fire alarm system.

The finding included:

Observation on 11/04/2019 at 2:47 PM, revealed a smoke detector to close to airflow in the corridor outside of room 15.
NFPA 101, 19.3.4.1 (2012 Edition), NFPA 101, 9.6.1.3 (2012 Edition) NFPA 72, 17.7.4.1 (2010 Edition)

The VP of operations was present when this deficiency was identified, and was later acknowledged during the exit conference on 11/04/2019.

Based on document review, the facility failed to maintain the sprinkler system.

The findings included:

Document review on 11/04/2019 at 12:13 PM, revealed the facility failed to provide documentation of a 5 year internal obstruction inspection. The last one was dated 11/07/2010.
NFPA 101, 19.3.5.1 (2012 Edition), NFPA 101, 9.7.5 (2012 Edition) NFPA 25, 14.2.1 (2011 Edition)

The VP of operations was present when this deficiency was identified, and was later acknowledged during the exit conference on 11/04/2019.

Based on observations, the facility failed to maintain the smoke barriers.

The findings included:

1. Observations on 11/04/2019 at 11:22 AM, revealed the following deficiencies above the ceiling inside of the materials/pharmacy room on the rated fire/smoke barrier wall:
a. Fire stop was cracking at the head of wall
b. ¼ inch conduit with wires not sealed
c. Bar joists were unsealed
d. Bar joists not sealed properly (sheetrock mud)
e. ¼ inch conduit not sealed properly (sheetrock mud)
NFPA 101, 8.3.5.1 (2012 Edition)

2. Observations on 11/04/2019 at 11:32 AM, revealed the following deficiencies above the ceiling inside of the classroom on the rated fire/smoke barrier wall:
a. Bar joists not sealed on the top and bottom throughout
b. Head of wall fire stop was cracking
NFPA 101, 8.3.5.1 (2012 Edition)

3. Observations on 11/04/2019 at 11:38 AM, revealed the following deficiencies above the ceiling outside of room 10 on the rated fire/smoke barrier:
a. ¼ inch conduits not properly sealed
b. Water lines not properly sealed
c. Cables with mixed fire stop
d. Insulated water lines with mixed fire stop
e. Head of wall not sealed correctly above HVAC duct
NFPA 101, 8.3.5.1 (2012 Edition)

4. Observations on 11/04/2019 at 11:51 AM, revealed the following deficiencies above the ceiling on the 2 hour rated fire/smoke barrier walls in the housekeeping room:
a. Not sealed at the deck
b. Steel trusses not sealed
c. ¼ inch conduits not sealed in the wall
d. (3) 3 inch pipes not sealed in the wall
NFPA 101, 8.3.5.1 (2012 Edition)

5. Observations on 11/04/2019 at 11:53 AM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier wall outside of the housekeeping room:
a. 5 inch insulated pipe with sheetrock loose
b. 1 cable sealed with sheetrock mud
NFPA 101, 8.3.5.1 (2012 Edition)

6. Observations on 11/04/2019 at 11:55 AM, revealed 2 steel trusses penetrating the elevator shaft wall that were not sealed by the nurses station.
NFPA 101, 8.3.5.1 (2012 Edition)

7. Observations on 11/04/2019 at 12:03 PM, revealed the following deficiencies on the rated fire/smoke barrier wall inside of central supply:
a. Bar joists not sealed properly
b. 3 inch insulated water line not properly sealed
c. Head of wall in the med room not properly sealed (mixed fire stop)
d. Wires throughout not properly sealed (mixed fire stop)
NFPA 101, 8.3.5.1 (2012 Edition)

8. Observations on 11/04/2019 at 12:10 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, at the nurses station:
a. Mixed fire stop at the head of wall
b. ¼ conduit with mixed fire stop
c. 1 bar joist not sealed
NFPA 101, 8.3.5.1 (2012 Edition)

9. Observations on 11/04/2019 at 12:11 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, above the medication prep room:
a. 1 inch copper lines not sealed
b. Sanitary pipe not sealed
c. Bar joists not sealed
NFPA 101, 8.3.5.1 (2012 Edition)

10. Observations on 11/04/2019 at 12:13 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, in the medication prep room:
a. ½ inch conduits not properly sealed
b. 2 inch sprinkler pipe not properly sealed
c. 1 inch insulated pipes not properly sealed
d. 7 x 7 inch improper sheetrock repair below the HVAC duct work
NFPA 101, 8.3.5.1 (2012 Edition)

11. Observations on 11/04/2019 at 12:18 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, inside of the soiled room by the nurses station:
a. 4 x 4 inch improper sheetrock repair by flex conduit
b. Steel truss not sealed
c. Sheetrock damage around ½ inch fire alarm conduit
d. Sheetrock damage at the bottom right of HVAC duct
e. Sprinkler unsealed on side wall
f. Head of wall unsealed
g. Mixed fire stop throughout the room
NFPA 101, 8.3.5.1 (2012 Edition)

12. Observations on 11/04/2019 at 12:40 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, inside of the lab:
a. Mixed fire stop around tresses throughout the lab area
b. ¼ inch flex from junction box not properly sealed
c. 5 insulated pipes from ½ inch to 1 inch unsealed
d. 3 x 3 inch improper sheetrock repair over the bulletin board
e. Steel trusses not properly sealed
NFPA 101, 8.3.5.1 (2012 Edition)

13. Observations on 11/04/2019 at 12:45 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, inside of the lab break room:
a. Mixed fire stop around steel trusses
b. Mixed fire stop at the deck
c. (4) ½ inch copper lines over refrigerator with mixed firestop
d. Mixed fire stop around conduit above the evacuation plan
NFPA 101, 8.3.5.1 (2012 Edition)

14. Observations on 11/04/2019 at 12:50 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, outside of the lab break room:
a. Mixed firestop around steel trusses
b. Penetration over door with mixed fire stop (putty with caulk)
c. Fire alarm conduit sealed on the right or bottom side
d. Insulated pipes not properly sealed
e. Steel trusses throughout the corridor of the lab
f. Mixed firestop at the deck throughout the corridor of the lab
NFPA 101, 8.3.5.1 (2012 Edition)

15. Observations on 11/04/2019 at 12:55 PM, revealed the unsealed steel trusses above the ceiling on the rated fire/smoke barrier, outside of the 2nd floor elevator.
NFPA 101, 8.3.5.1 (2012 Edition)

16. Observations on 11/04/2019 at 12:57 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, outside of the lab (by the vending machines):
a. Mixed fire stop around insulated pipes
b. Deck improperly sealed
c. 12 foot x 18 foot improper sheetrock repair
NFPA 101, 8.3.5.1 (2012 Edition)

17. Observations on 11/04/2019 at 1:06 PM, revealed the steel trusses by the CT elevators on the 1st floor were not correctly sealed, above the ceiling on the rated fire/smoke barrier wall.
NFPA 101, 8.3.5.1 (2012 Edition)

18. Observations on 11/04/2019 at 1:11 PM, revealed a ¾ inch conduit not properly sealed, above the ceiling on the masonry rated fire/smoke barrier wall in the ER storage room.
NFPA 101, 8.3.5.1 (2012 Edition)

19. Observations on 11/04/2019 at 1:13 PM, revealed the top of a beam at the deck was not sealed, above the ceiling on the rated fire/smoke barrier wall on the back wall of ER 6 and the ER 6 restroom.
NFPA 101, 8.3.5.1 (2012 Edition)

20. Observations on 11/04/2019 at 1:18 PM, revealed the following deficiencies, above the ceiling on the rated fire/smoke barrier wall outside of the ER biohazard room:
a. Deck not properly sealed
b. Electrical conduits not properly sealed
c. 4 inch metal sleeve below HVAC not sealed
d. 2 inch metal sleeves not sealed
NFPA 101, 8.3.5.1 (2012 Edition)

21. Observations on 11/04/2019 at 1:21 PM, revealed the following deficiencies, above the ceiling on the rated fire/smoke barrier wall inside of the ER biohazard room:
a. Bar joist not sealed
b. HVAC duct not properly sealed
c. Metal stud at a 45 degree angle into the wall not properly sealed
d. Insulated pipes with mixed firestop/sheetrock mud
e. Multiple improper sheetrock repairs
f. Improper firestop/penetrations unsealed throughout the room
NFPA 101, 8.3.5.1 (2012 Edition)

22. Observations on 11/04/2019 at 1:26 PM, revealed the following deficiencies, above the ceiling on the rated fire/smoke barrier wall in room 9:
a. Unsealed 4 inch x 4 inch penetration
b. ¼ inch flex not properly sealed
c. 1 inch line unsealed
d. ½ inch copper line unsealed
e. Top of beam unsealed across the wall
NFPA 101, 8.3.5.1 (2012 Edition)

23. Observations on 11/04/2019 at 1:31 PM, revealed the following deficiencies, above the ceiling on the rated fire/smoke barrier wall outside of the procedure break hall:
a. Top of beam unsealed
b. 1 inch copper pipe with single wire not properly sealed
c. 5 inch metal sleeve not sealed
NFPA 101, 8.3.5.1 (2012 Edition)

24. Observations on 11/04/2019 at 1:34 PM, revealed the following deficiencies, above the ceiling on the rated fire/smoke barrier wall in the women's locker room:
a. Galvanized sprinkler improperly sealed
b. All thread hangar tapped
c. ½ conduit through wall not properly sealed
NFPA 101, 8.3.5.1 (2012 Edition)

25. Observations on 11/04/2019 at 1:39 PM, revealed the following deficiencies, above the ceiling on the rated fire/smoke barrier wall, above the cross corridor doors outside of the kitchen:
a. ¼ inch fire alarm conduit with mixed fire stop
b. Smooth conduit not properly sealed
c. 2 inch insulated lines not properly sealed
d. ¼ inch lines not properly sealed
e. Putty mixed with caulk in conduits
f. Flex conduit not properly sealed on the right side
g. 10 inch water return lines not properly sealed
NFPA 101, 8.3.5.1 (2012 Edition)

26. Observations on 11/04/2019 at 1:40 PM, revealed multiple penetrations (trusses, smooth conduits, copper lines, etc) sealed with sheetrock mud and not fire stop, above the ceiling on the rated fire/smoke barrier wall outside of the kitchen (across from panels labeled "D")
NFPA 101, 8.3.5.1 (2012 Edition)

27. Observations on 11/04/2019 at 1:42 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier wall outside of the facility engineer/powerhouse room:
a. Joint tape peeling at the deck
b. Trusses not sealed
c. Mixed fire stop around 3 inch metal sleeve with a copper line
NFPA 101, 8.3.5.1 (2012 Edition)

28. Observations on 11/04/2019 at 1:46 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier wall outside of the PT access manager office:
a. Insulated pipe that 45 degree angles into the wall not properly sealed
b. 2 insulated pipes not sealed properly
c. Mixed fire stop around multiple conduits and pipes
d. Steel trusses not sealed
e. 12 inch by 12 inch Improper sheetrock repair above the restroom vestibule door
f. Multiple conduits throughout have sheetrock mud mixed with fire stop
NFPA 101, 8.3.5.1 (2012 Edition)

29. Observations on 11/04/2019 at 1:48 PM, revealed the following deficiencies above the ceiling on the 2 hour rated fire/smoke barrier wall outside of the engineers door:
a. Multiple conduits throughout have mixed fire stop
b. Steel trusses not sealed in the middle
c. 1 ½ inch PVC with sheetrock mud (between engineer and electric panel)
d. 3 inch sprinkler line with mixed fire stop
e. Hot water return line and supply line mixed fire stop
NFPA 101, 8.3.5.1 (2012 Edition)

30. Observations on 11/04/2019 at 1:46 PM, revealed the following deficiencies above the ceiling on the 2 hour rated fire/smoke barrier wall outside of the kitchen:
a. 4 insulated water lines not sealed on the top and mixed fire stop on the bottom
b. 1/4 inch Fire alarm conduit unsealed on the bottom
c. Bottom of structural beam mixed fire stop/not properly sealed
NFPA 101, 8.3.5.1 (2012 Edition)

31. Observations on 11/04/2019 at 2:55 PM, revealed the following deficiencies in the IT room on the rated fire/smoke barrier wall:
a. ½ inch conduits with mixed fire stop
b. 2 flex conduits with improper fire stop (sheetrock mud) over the radios
NFPA 101, 8.3.5.1 (2012 Edition)

The VP of operations and maintenance were present when these deficiencies were identified, and were later acknowledged during the exit conference on 11/07/2019.