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Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2.

Findings include:

A. A steel beam was observed, immediately south of the North Entry Vestibule, that is not fireproofed in a manner consistent with the designated building construction type; refer to NFPA 220 1999 3-1.

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

Findings include:

A. Staff work areas in the West Smoke Compartment, which were observed to be open to the smoke compartment corridors, were observed to lack smoke detectors required by Exception 6. [subpart(a)] to 19.3.6.1., AND WERE ALSO observed to lack sprinkler coverage required by Exception 6. [subpart(b)] to 19.3.6.1. Locations observed include:
1. Surgery Department Copy Room (room lacks door to Corridor).
2. Administrative Assistant's Office (walls of room do not extend to the underside of the deck above).



14416


By direct observation the surveyor finds:

In the west smoke compartment the interstitial space between the ceiling of the corridors and the roof deck is being used as a common plenum for ventilation exhaust air for the entire compartment. Transfer of exhaust air from rooms off the corridor is by way of transfer grills installed in the corridor walls as prohibited by NFPA 101, 19.3.6.4.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. The door to the Ambulance Supervisor's Office was observed to not be a side-hinged, swinging door as required by 7.2.1.4.1.

Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 19.3.7.5., 19.3.7.6., and 19.3.7.7.

Findings include:

A. The door to the Emergency Department Pyxis Room, which is located in a smoke barrier wall, was observed to be held open by an unapproved device (a door wedge) as prohibited by 19.3.7.6.

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

Findings include:

A. Pipe or other penetrations through enclosure walls of hazardous areas not covered by a sprinkler system were observed that are not sealed against the passage of fire as required by 19.3.2.1. and 8.2.3.2.4.2. Locations observed include:

1. X-Ray File Room.
2. Surgery Storage Room.

3. Hazardous Materials Storage Room.

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

1. Storage Room containing H1N1 supplies.
2. Medical Records File Room 1.

3. Medical Records File Room 2.

4. Medical Records Office.
5. Soiled Utility Room.

C. The door to the Soiled Linen Room was observed to not close to latch as required by 19.3.2.1. and 8.2.3.2.3.1.(2).

D. The door to the Purchasing Storage Room was observed to be held open by an unapproved device (a door wedge) as prohibited by 19.3.2.1. and 8.2.3.2.3.1.(2).

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. The door from the Hospital to the Glass Corridor/Cafeteria Building, located in a designated 2 hour fire barrier, was observed to not close to latch as required by 7.2.4.3.8. and 8.2.3.2.3.1.(1).

Based on random observation during the survey walk-through and staff interview, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. During an interview held at the site on the morning of January 20, 2010, the provider's Director of Facilities stated that the path from the west end of the Hospital (immediately east of the door to the Nursing Home) toward the Glass Corridor/Cafeteria Building should be identified as an exit path. Thus the deficiencies cited below exist based on 7.10.:
1. No exit sign was observed which direct building occupants from the Corridor immediately east of the door to the Nursing Home toward the Glass Corridor/Cafeteria Building (through the Corridor immediately east of the Soiled Linen Room).
2. No exit sign was observed above the north side of the door from the Hospital into the Glass Corridor/Cafeteria Building.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. Locations observed include:

1. The egress path toward the north exit door.
2. The egress path toward the southeast exit door.

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

Findings include:

A. At Electrical Panel B1, the circuit breaker serving the Fire Alarm Control Panel was observed to not be in compliance with NFPA 72 1999 1-5.2.5.2. because it is not equipped with a mechanical lock-on device, is not labeled, and is not painted red.

B. The north side of the door from the Hospital to the Glass Corridor/Cafeteria Building (which is located in a designated horizontal exit) was observed to lack a manual fire alarm pull station required by 9.6.2.1(1) and NFPA 72 1999 2-8.2.2.

C. During a test of the building fire alarm system conducted on the afternoon of January 20, 2010, the smoke detector located near the exit door from the Glass Corridor/Cafeteria Building (immediately south of the Hospital) was observed to not activate the Hospital fire alarm annunciation system as required by 9.6.2.1(2).

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. Carts and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. Corridor across from Emergency Department Nurses' Station, medications cart.

2. Emergency Department Vestibule, wheelchairs.

Based on direct observation and staff interview, the facility failed to provide:

1. Starting battery heater w/ auto shutoff for the emergency generator. (NFPA 110, 3-3.1)

2. Provide a remote manual emergency stop station for the emergency generator.
(NFPA 110, 1999, 3-5.5.6)

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. Materials were observed being stored less than 18" below sprinkler heads as prohibited by NFPA 13 1999 5-6.6. (for standard pendant and upright spray sprinkler heads) and 5-7.6. (for standard sidewall sprinkler heads). Locations observed include:

1. Purchasing Storage Room.

2. Supply Room 114.

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

Findings include:

A. Because not all Emergency Department Treatment Rooms were accessible during the survey walk-through, it could not be determined whether each Treatment Bay complies with those requirements listed below:

1. It could not be determined whether the electrical receptacles served by the building emergency electrical system at these critical care patient beds are labeled as to panel and circuit number as required by NFPA 70 1999 517-19(a).

2. It could not be determined whether each Treatment Bay is provided with a minimum of 6 electrical receptacles as required by NFPA 70 1999 517-19(b).

Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2.

Findings include:

A. A steel beam was observed, immediately south of the North Entry Vestibule, that is not fireproofed in a manner consistent with the designated building construction type; refer to NFPA 220 1999 3-1.

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

Findings include:

A. Staff work areas in the West Smoke Compartment, which were observed to be open to the smoke compartment corridors, were observed to lack smoke detectors required by Exception 6. [subpart(a)] to 19.3.6.1., AND WERE ALSO observed to lack sprinkler coverage required by Exception 6. [subpart(b)] to 19.3.6.1. Locations observed include:
1. Surgery Department Copy Room (room lacks door to Corridor).
2. Administrative Assistant's Office (walls of room do not extend to the underside of the deck above).



14416


By direct observation the surveyor finds:

In the west smoke compartment the interstitial space between the ceiling of the corridors and the roof deck is being used as a common plenum for ventilation exhaust air for the entire compartment. Transfer of exhaust air from rooms off the corridor is by way of transfer grills installed in the corridor walls as prohibited by NFPA 101, 19.3.6.4.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. The door to the Ambulance Supervisor's Office was observed to not be a side-hinged, swinging door as required by 7.2.1.4.1.

Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 19.3.7.5., 19.3.7.6., and 19.3.7.7.

Findings include:

A. The door to the Emergency Department Pyxis Room, which is located in a smoke barrier wall, was observed to be held open by an unapproved device (a door wedge) as prohibited by 19.3.7.6.

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

Findings include:

A. Pipe or other penetrations through enclosure walls of hazardous areas not covered by a sprinkler system were observed that are not sealed against the passage of fire as required by 19.3.2.1. and 8.2.3.2.4.2. Locations observed include:

1. X-Ray File Room.
2. Surgery Storage Room.

3. Hazardous Materials Storage Room.

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

1. Storage Room containing H1N1 supplies.
2. Medical Records File Room 1.

3. Medical Records File Room 2.

4. Medical Records Office.
5. Soiled Utility Room.

C. The door to the Soiled Linen Room was observed to not close to latch as required by 19.3.2.1. and 8.2.3.2.3.1.(2).

D. The door to the Purchasing Storage Room was observed to be held open by an unapproved device (a door wedge) as prohibited by 19.3.2.1. and 8.2.3.2.3.1.(2).

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. The door from the Hospital to the Glass Corridor/Cafeteria Building, located in a designated 2 hour fire barrier, was observed to not close to latch as required by 7.2.4.3.8. and 8.2.3.2.3.1.(1).

Based on random observation during the survey walk-through and staff interview, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. During an interview held at the site on the morning of January 20, 2010, the provider's Director of Facilities stated that the path from the west end of the Hospital (immediately east of the door to the Nursing Home) toward the Glass Corridor/Cafeteria Building should be identified as an exit path. Thus the deficiencies cited below exist based on 7.10.:
1. No exit sign was observed which direct building occupants from the Corridor immediately east of the door to the Nursing Home toward the Glass Corridor/Cafeteria Building (through the Corridor immediately east of the Soiled Linen Room).
2. No exit sign was observed above the north side of the door from the Hospital into the Glass Corridor/Cafeteria Building.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.1. Locations observed include:

1. The egress path toward the north exit door.
2. The egress path toward the southeast exit door.

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

Findings include:

A. At Electrical Panel B1, the circuit breaker serving the Fire Alarm Control Panel was observed to not be in compliance with NFPA 72 1999 1-5.2.5.2. because it is not equipped with a mechanical lock-on device, is not labeled, and is not painted red.

B. The north side of the door from the Hospital to the Glass Corridor/Cafeteria Building (which is located in a designated horizontal exit) was observed to lack a manual fire alarm pull station required by 9.6.2.1(1) and NFPA 72 1999 2-8.2.2.

C. During a test of the building fire alarm system conducted on the afternoon of January 20, 2010, the smoke detector located near the exit door from the Glass Corridor/Cafeteria Building (immediately south of the Hospital) was observed to not activate the Hospital fire alarm annunciation system as required by 9.6.2.1(2).

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. Carts and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. Corridor across from Emergency Department Nurses' Station, medications cart.

2. Emergency Department Vestibule, wheelchairs.

Based on direct observation and staff interview, the facility failed to provide:

1. Starting battery heater w/ auto shutoff for the emergency generator. (NFPA 110, 3-3.1)

2. Provide a remote manual emergency stop station for the emergency generator.
(NFPA 110, 1999, 3-5.5.6)

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. Materials were observed being stored less than 18" below sprinkler heads as prohibited by NFPA 13 1999 5-6.6. (for standard pendant and upright spray sprinkler heads) and 5-7.6. (for standard sidewall sprinkler heads). Locations observed include:

1. Purchasing Storage Room.

2. Supply Room 114.

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

Findings include:

A. Because not all Emergency Department Treatment Rooms were accessible during the survey walk-through, it could not be determined whether each Treatment Bay complies with those requirements listed below:

1. It could not be determined whether the electrical receptacles served by the building emergency electrical system at these critical care patient beds are labeled as to panel and circuit number as required by NFPA 70 1999 517-19(a).

2. It could not be determined whether each Treatment Bay is provided with a minimum of 6 electrical receptacles as required by NFPA 70 1999 517-19(b).