HospitalInspections.org

A) The Main Hospital is 13 stories in height and is reported as Type I (332) Construction (as defined by NFPA 220 - 1999). Portions of the building were found to have unprotected structural steel.

1). Corrected 10/21/09

2). Basement Level Center Core Stair: The north wall of this stair is a double wall below the ceiling/ Although access above the ceiling on the corridor side of this wall is difficult, the surveyor finds that a portion of the outer wall (corridor wall side, above the ceiling) is missing, exposing steel columns at two corners of the stair and exposing steel beams radiating out from the columns. The masonry enclosure (as protection for the columns is missing exposing the entire column and the steel beams that lack fire proofing.
5/12/10 - the above item was found corrected at the Basement Level.

a) Similar conditions were above
ceilings at this stair on the 6th Floor.

3). Corrected 5/25/11

4) A portion of the 1st Floor, starting in the northern portion of the La Boure Clinic and extending south into Radiation Oncology was at one time an Auditorium. This portion of the building currently has large steel truss girders at 24" on center and most likely other steel elements that are protected by monolithic ceilings. Some of the ceilings are suspended lathe and plaster while other ceilings are suspended drywall. These monolithic ceilings are located above the acoustical lay-in ceilings in this area.

a) Documentation for either system as a
two hour fire rated floor/ceiling
assembly was not available on site (No
U L Design Numbers).

b) Multiple access panels were above.
Some were found open, most if not all
were not self closing. Documentation
that identifies how the access panels are
part of a tested assembly was not
available. The provider lacks adequate
means to keep the access panels closed.

c) Voids and unsealed penetrations were
observed in the monolithic ceiling. The
steel above was unprotected.

d) Multiple ducts penetrate vertically
through the monolithic ceilings. No U L
Design numbers are available to
demonstrate how the ducts are permitted
to penetrated the barrier, whether fire
dampers are provided or not. No fire
dampers were found.

5) Corrected 5/25/11
6) Corrected 5/25/11




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A) Based on random observation the surveyor finds that corridor doors lack positive latching hardware in accordance with 19.3.6.3.2. Locations observed:

1. Corrected 5/25/11

2. 4th floor C-Section rooms, the pairs of
doors leading from each C-Section
room to the adjacent corridor (facility
life safety plans do not indicate this
area to be a suite) lack latching
hardware.

A) From random observations, the surveyors find that vertical openings are not enclosed and protected in accordance with 19.3.1.1 and NFPA 90A. Some shafts but not all shafts are identified on the 2009 Life Safety Code Plans. Also, some shafts are identified with no enclosure indicated; some shafts are identified with non-combustible shaft enclosure and some are identified with two hour fire rated enclosures. In too many locations to list, the surveyors observed shaft enclosures that were not enclosed in fire rated enclosures. General deficiencies include but are not limited to:

* Shafts are open to the ceiling cavities of adjacent spaces.

* Shafts are not enclosed in fire rated construction

* Shafts have multiple penetrations or voids that are not sealed or they are sealed with unrated materials

* Shafts have access panels that are not fire rated and not self closing

* Many shafts are inaccessible and cannot be inspected.

* See K067

Locations include but are not limited to:

1) (Modified 10/22/09) 1963 Building Basement Machine Room: this space is open and unseparated from one or more vertical shafts. The space lacks fire dampers where required by NFPA 90A. See also K067

2) Corrected 5/25/11
3) Deleted 5/25/11
4) Deleted 5/25/11
4.5) Corrected 10/21/09
5) Deleted 5/25/11

6) The Northwest Stair at the 1st Floor has shafts on three sides of the stair. These shafts have several sleeves or penetrations that are not sealed with fire rated materials. The shafts are open to the ceiling cavity of an adjacent locker room (surveyor notes indicate at Northeast corner of shaft - but this location may not be accurate).

a) One shaft has only one layer of drywall and multiple voids, above the ceiling in the locker room. The surveyor noted that the pipe chase at this location continues up as a vertical opening.

7) Deleted 5/25/11

8) 1st Floor near Entrance C (next to Emergency Department) There is a large duct shaft (T1207)that is shown with a two hour fire rated enclosure. Two ducts penetrate this shaft above the ceiling. Fire dampers and fire damper access panels were not found.

9) 1st Floor Shaft at the south end of the Emergency Department (T1159) and at the north end of Radiation Oncology: Multiple ducts penetrate the shaft above the ceiling. Fire dampers and fire damper access panels were not found. At least multiple duct penetrations have a label that indicates that the fire damper was removed.

10) Corrected 5/25/11

11). 2nd Floor Electrical Closet (T2034): The duct penetration into the adjacent shaft has a label on the access panel that indicates that the fire damper was removed (actually it was disabled) on 12/32/02. The surveyor also notes that the disabled fire damper was not installed in the plane of the fire barrier.

12). 2nd Floor: There is a duct shaft (T2201) in a corner next to Elevator 1 and 2; one or more duct penetrations above the ceiling lack fire dampers.

13). 2nd Floor: There is a duct shaft (T2196) in a corner next to Elevator 3 and 4; one or more duct penetrations above the ceiling lack fire dampers.

14. Corrected 12/28/10.
15. Corrected 12/28/10.
16. Corrected 12/28/10.
18. Corrected 12/28/10.

19). 2nd Floor shaft west of the Service Elevators: Access was available on one site only and the plans are not accurate for this area. Two duct penetrations above the ceiling lacked fire dampers - label says that they were removed.

20. Corrected 12/28/10.
21. Corrected 5/25/11
22. Deleted 5/25/11
23. Corrected 5/24/11



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B) The surveyor finds a number of fire dampers that are not installed in accordance with NFPA 90A. The surveyor was not able to get into many locations where fire dampers might be confirmed because many of the rooms contained gypsum board ceilings which lacked access panels (and the dampers were not accessible).

1) Corrected 5/24/11

2) Three ducts penetrate at least 7 floors without being enclosed in a 2 hour fire rated shaft enclosure to comply with NFPA 90A 1999 3-3.4.1. Surveyor observed these ducts within a telecommunications closet. This "closet" is currently part of a ventilation shaft on each floor but does not comply with NFPA 90A for a 2-hour enclosure. The conditions cited are as follows:

a. These ducts originate in the 13th floor
penthouse and terminate above the
ceiling of the 6th floor. Surveyor did not
fire the refernced ducts are enclosed in
a continuous fire rated shaft enclosure.
Therefore the room is part of the shaft
enclosure on each floor and is deficient
on multiple floors.

b. Example: The communication closet
titled Telecom # T12042 - 12th floor (on
the life safety plan) includes the ducts
from the 13th floor mechanical room.
This shaft enclosure does not provide a
continuous fire rated separation due to
the following:

i) The walls of the closet could not be
determined to provide a U.L. listed
2-hour fire rated wall assembly.

ii) The walls of the closet were not
continuously sealed against the
passage of smoke and fire.

iii) Corrected 12/28/10.
iv) Corrected 12/28/10.
v) Corrected 12/28/10.

c. The 6th floor duct exiting the closet
enclosure lacks a damper installation to
comply with NFPA 90A 1999 3-3.4.4.

d. Deleted 5/25/11


C.) A duct penetration through a designated 2 hour fire resistant shaft was observed that, due to the lack of fire damper, allowed the passage of smoke and fire between floor levels. This condition does not comply with NFPA 90A 1999 3-3.2. This condition was observed for this shaft on each floor level. Locations observed include but are not limited to:

1. Eleventh floor, shaft T 11065 adjacent to
Patient room # 1130 (room numbers
according to facility life safety plan).

2. This same "shaft" is incomplete.
Example: 9th floor. Surveyor viewed
into the "shaft" enclosure (as indicated
on the facility life safety floor plan) and
observed vertical pipe runs. This "shaft"
is open to the adjacent occupiable
spaces via the wardrobe closets.

It could not be
determined due to lack of access,
whether the pipes are sealed at each
floor penetration to comply with
8.2.3.2.4,or if the ductwork contains fire
dampers to comply with NFPA 90A.

D) Multiple floors and multiple locations: Shafts are identified on the 2009 Life Safety Code Plans as: "noncombustible shaft enclosure (example: T9039)," some shafts are identified with two hour enclosures (Example: T9139) while others are indicated as "shafts" (with no enclosure identified - example: 9th floor T9066 & T9068).

Example location 9th Floor - shaft T9026 (according to facility life safety plans) The "central core" contains large duct "shafts" on each floor level. Some shafts are identified on the facility life safety drawings as a "noncombustible shaft enclosure" while others are indicated as "shafts (example 9th floor T9068). All indications for shafts lack a 2-hour fire resistant rating to comply with 19.3.1.1.

1. There are no fire dampers in the walls where ducts leave these shafts.

2. There are no access doors to allow an inspection of these shafts.

E) 13th floor Exhaust Fan room for the South East toilet rooms- Surveyor observed duct and pipe penetrations through a designated 2- hour fire rated shaft wall installation (according to the facility Life Safety Plan). The Exhaust fan room is considered part of the vertical shaft installation but does not comply with the requirements for vertical separations due to the following:

1. The designated shaft wall was
incomplete and did not extend tight to
the underside of the roof ceiling
structure above.

2. The ducts lacked damper installations.

3. The pipes were not sealed against smoke
and fire.

A) From random observation, the surveyors find that required exit stair enclosures do not comply with Chapter 7.1.3.2 of NFPA 101.

1) Stair construction throughout the facility is similar on every floor for every stair. The stair stringers and the landing support channels are recessed one inch into the masonry walls that enclose the stair.

a) The original construction documents
called for the exposed stair stringers and
channels to be fire proof on the outer
side enclosure wall of the stair. This
was not found in any location where
access is possible.

b) In some parts of the building, the outer
walls of the stair is an additional layer of
concrete block that conceals and protects
the referenced steel at the outer
enclosure walls.

c) In some locations the steel stringers and
channels are visible from access panels
in walls or they are visible above
ceilings (exposed - through any and all
masonry)

d) Most stairs have a pipe chase on one or
more sides of the Stair. Some stairs also
have duct shafts immediately adjacent to
the stair. Although access is difficult,
from random observation, the surveyors
find the the stair stingers and the landing
support channels are open and exposed
to the shafts in some locations. It was
not possible to access the duct shafts
to determine if any fire separation is
provide for the stairs.

e) The pipe chases that are adjacent to
stairs are difficult to access and are
difficult to inspect; however from
random locations the surveyors have
observed that many of these pipe chases
are continuous vertically through the
building (see also K020).

5/12/10: Based on observation, the surveyor finds that some portions of the above citation have been corrected. The above items will not be cleared until compliance at all locations can be confirmed (this includes confirmation of any FSES that is submitted).

5/25/11: Based on observation, the surveyor finds that some portions of the above citation have been corrected. The above items will not be cleared until compliance at all locations can be confirmed (this includes confirmation of any FSES that is submitted).


2) Given the above conditions and the citations below, the surveyors find that none of the required exit stairs are enclosed in one hour fire rated construction in accordance with 7.1.3.2.1 b) exception # 2. At best the stairs are enclosed only with barriers that will resist passage of smoke

Basement Level Center Core Stair:

3) Center Core Stair

a) Corrected 10/21/09

b) Basement Level:
The north wall (corridor wall) of the stair
has a double wall or chase. The chase it
open to the ceiling cavity of the adjacent
corridor. The inner wall of the stair has
a fire hose/standpipe riser cabinet that
penetrates into the chase. The only
separation between the stair and the
ceiling of the corridor is the metal
cabinet which is not fire rated

c) A fire hose cabinet is recessed into the
pipe chase next to the stair. The pipe
chase is open to the ceiling cavity of the
adjacent corridor. The only separation
between the corridor and the stair is the
sheet metal in the fire hose cabinet -
which is not fire rated.

The last submitted PoC for item b and c were
scheduled to be corrected by 4/16/10.
On 5/12/10, the provider was unable to
demonstrate how they had been corrected.

4) North Stair (Northeast Stair of 1963 Building):

a) See Item 1 above

b) One wall of the stair has two access
panels (for access into the adjacent
chase). Neither access panel is fire
rated. One of the panels is a steel plate
that is bolted to the wall. This access
panel was not installed to be smoke
tight. (Basement)

c) The fire hose/standpipe cabinet in this
stair is recessed through the stair wall
into the adjacent pipe chase. This
opening in the stair wall is not fire rated.
(Basement)

d) The adjacent chase is not enclosed in fire
rated construction; the stair is separated
from adjacent spaces by unrated
materials - see K020. (Basement)

e) The stair stringers are exposed to the
adjacent pipe chase on multiple levels
(masonry or fire proofing is missing to
separate the stair from the chase).

f) A 2nd Floor access panel into an
adjacent shaft is not fire rated.


5) Southeast Stair

a) See Item 1 above

b) The Basement intermediate landing has
an access panel into the adjacent
chase that is not fire rated.


6) North Stair (actually the Northeast Stair): This stair discharges at the 1st Floor directly outside with no access from the 1st Floor. The stair has shaft enclosures on three sides of the shaft. The stair is identified with a two hour fire rated enclosure. The stair enclosure is deficient at the 1st F floor and possible other floors:

a) There is a fire hose cabinet recessed
into the stair wall/shaft wall. The
cabinet is a unprotected opening in this
fire barrier. The adjacent shaft is open to
the Basement Mech. Room.

b) The stair stringer(s) are exposed on both
sides of the stair wall. The stair stringers
are exposed to the adjacent pipe chase
on multiple levels (masonry or fire
proofing is missing to separate the stair
from the chase).

c) See K020




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C) Numerous access panels in designated exit stairs throughout the facility (stair shafts are indicated on the facility life safety drawings as fire resistant enclosures) do not maintain the fire resistant separation of the stair to comply with 19.3.1. and 7.1.3.2.2 Example conditions include:
* Numerous panels do not carry a minimum 1 1/2 hour fire resistant rating due to the lack of a U.L. listed label.

* Numerous panels are not self-closing to comply with 8.2.5.4(1) and 8.2.3.2.3.1(1). The access doors when released did not close to latch on their own.

* The stair wall opening at the access doors is not sealed to prevent the passage of smoke and fire to comply with 8.2.5.4(1) and 8.2.3.2.4.2. Surveyor observed unsealed concrete block cores.

Example locations include:

1. "Center core stair" designated exit stair - intermediate landing between 6th and 7th floors. Numerous large metal panels are surface mounted to the concrete block stair wall and lacked a U.L. label indicating the fire resistance of the installation to comply with 8.2.5.2 as appropriate for the fire rating of the stair.

2. "Center core stair" - Basement level - surface attached access panels.

3. "Center core stair" - Intermediate landing 8th and 9th floors - access panel installation with unsealed concrete block cores at the perimeter.

4. North Stair - 5th Floor access panel labeled "Honeywell J-B".

5. East Stair - 3rd and 4th Floor access panels.


D) Surveyor viewed a large opening in the concrete block shaft wall located on the South side of the stairway. The opening was observed from an access panel within the stair. The shaft opening is approximately 3 feet long by 16 inches tall. The surveyor was able to view into the interstitial space above a gypsum board ceiling of the adjacent occupied space. This does not comply with 19.3.1.1. Location observed" "Center core stair" designated exit stair - intermediate landing between 8th and 9th floors - view into room # 909 (facility life safety plan).

A) (Modified 10/22/09): three of three exit stairs, failed to provide and maintain a protected path to a public way in accordance with 39.2.7 and 7.7.1 or 7.7.2 of NFPA 101, for each stair.

1) South Stair: This stair discharges into a large 2nd Floor Lobby that is open to much of this floor. The exit lacks a two hour fire rated (protected) path to the outside in accordance with 7.7.1, 7.7.2 or 7.2.6.

2) Corrected 5/24/11

3) (New 10/22/09): The Basement Level Tunnel from the Hospital terminates at a foyer in the Manor Building. The exit path out of this foyer is via a one story stair that lacks a protected path to the outside in accordance with 7.7.1.

A) Exit stairs are not configured and constructed to comply with 7.7.1 and/or 7.7.2: There are four required exit stairs from the Basement Level. The same four exit stairs are the only exit stairs that serve the 5th Floor and above (Northeast Stair, Southwest Stair, Center Core Stair and Southeast Stair).

1) The Northeast Stair and the Center Core Stair do not discharge as a protected path to the outside in accordance with 7.7.1. These two stairs only comply with 7.7.2 if the other two stairs comply with 7.7.1. The Southeast Stair complies with 7.7.1.
The Southwest Stair discharges into a 1st Floor exit passageway that does not comply with 7.2.6 and 7.7.1.

a) The "exit passageway" for the Southwest
Stair is not identified specifically on the
Life Safety Plans as an exit passageway.
It is shown as a corridor space with two
hour or four hours barriers that extend
from the discharge doors to a four hour
Chicago vestibule north of Dietary. The
exit passageway does not comply as a
two hour fire rated exit passageway.

b) Multiple ducts penetrate the above
referenced two hour and four hour fire
barriers, above ceilings. While some
duct penetrations may have fire
dampers, many duct penetration lack fire
dampers and/or fire damper access
panels. One or more ducts have access
panels that indicate that the fire
dampers were removed. (see also K067)

c) Corrected 10/22/09
d) Deleted 5/24/11

2) The southwest stair isa required exit for the 12 story bed tower. The exit changes direction and transfers through a vestibule at the 2nd Floor and then continues as an exit stair, discharging at the 1st Floor. This 2nd Floor vestibule can only be an exit passageway. The vestibule does not comply with 7.2.6 as an exit passageway:

a) It is not identified on plans as an exit
passageway.

b) Two or more ducts penetrate the
designated/required two hour walls of
this vestibule and do not have fire
dampers in accordance with NFPA 90A

c) Corrected 12/28/10.

A) From random observation the surveyors find that means of egress are not readily available at all times:

1) Corrected 10/22/09
2) Corrected 12/28/10.
3) Corrected 5/24/11



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B). Corrected 12/28/10.
C) Corrected 12/28/10.

D) The 5th floor exit access corridor near the three Services Elevators has two paths of egress; 2nd path of egress is directed with exit signs into the ICU Suite. This constitutes a dead-end corridor condition (the corridor may not terminate or pass through the suite as a complying means of egress).





.

A) Corrected 12/28/10.



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B). Based on random observation during the survey walk through the surveyor noted a designated suite (as shown on the facility life safety plan) which does not comply with 19.2.5.6 for the size of a patient sleeping room.

Location observed: Fifth Floor ICU suite (approx 5,461 s.f..) exceeds the square footage allowed by the Life Safety Code for a patient sleeping room. See also K038.




.

A) From random observation, the surveyors find that fire barriers (with two hour or greater fire ratings) are not installed and maintained in accordance with 8.2.3. This includes fire barriers that are used as horizontal exits and fire barriers that are used to separate buildings:

1) Deleted

2) The 1st Floor Exit Passageway for the Southwest Stair has designated two hour and four hour barriers (see also K033). The east wall of this area is a designated four hour barrier. Duct penetrations through this barrier do not have fire dampers or fire dampers have been removed (see also K067).

3) Corrected 5/25/11.
4) Corrected 5/25/11.
5). Corrected 5/25/11.
6) Corrected 5/24/11

7) 1st Floor Corridor, north of the Gift Shop:

a) Corrected 12/28/10.

b) Large round duct penetrates the fire barrier; there was no evidence of a
fire damper or fire damper access panel

8) Corrected 5/25/11.
9) Corrected 5/25/11.
10) Corrected 5/25/11.
11) Corrected 12/28/10.



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B). Through wall duct penetrations were observed through designated 2-hour or greater fire rated wall installations that are not equipped with fire dampers as required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1.

Location observed: Fifth floor "Critical nurse manager" room located east of telecom room #T5009. The North wall of this room is designated as a 3-hour fire/smoke barrier according to the facility life safety plan. A duct penetrating this wall lacks evidence of a fire damper. No access panel is provided; no fire damper could be observed. Also, no retaining angles were observed on the through wall duct penetration.




.

A) (5/12/10 New): The provider lacks effective means to confirm that corrective actions have been completed in accordance with the submitted PoC, by the dates identified in the PoC. The provider failed to revise the PoC, in writting and submit modified form 2567 with revised correction dates, prior to the dates that expired. Based on the survey of 5/12/10, there were a significant number of items taht should have been corrected that were not.

B) (5/12/10 New): The provider was not able to identify where and how a number of items had been corrected. Accurate plans with rated barriers, etc were not available and the provider was unable to find room numbers for rooms that corrective actions were made. The rooms numbers used in the citations were furnished by the provider on previous surveys.

C) (5/25/11): The provider was not able to identify where and how a number of items had been corrected. Floor plans with rated barriers, etc were available however, the provider was unable to locate room numbers and K-Tag items which could be located from the provider's Life Safety floor plans. The rooms numbers used in the citations were furnished by the provider on previous surveys. An accurate tracking method for each item on the Statement of Deficiency was not available.

A) Based upon document review and personnel interviews, the surveyors find that the sprinkler systems are not tested, serviced and maintained in accordance with NFPA 25.

1) Two of two fire pumps

a. Corrected 5/12/10

b. Documentation of annual testing of the
fire pumps, including testing on
emergency power in accordance with 5-
3.3.4 (NFPA 25 - 1999), was not available.

5/12/10 - documentation was incomplete

c. 5/12/10 deleted - refer to K063

2) Building sprinkler system (The building is fully sprinklered except where indicated in K056):

a. Documentation of quarterly flow testing
was incomplete. 5/12/10: The quarterly
report of 2/23/10, identifies locations:
that were skipped, devices that were
not accessible, and devices that are not
wired to the fire alarm. Also, a tamper
switch on a pump discharge failed the
test and was identified as "to be
corrected ASAP."

b. The documentation of annual testing,
service and maintenance is incomplete:

Corrected 5/12/10: exercise of valves

Corrected 10-22-09: Lube of valves

10/22/09: Documentation still does not
indicate that all gauges are calibrated or
replaced every five years and the
documentation does not include last date
that this was done.

5/12/10 - The above item has not been
corrected in accordance with the last
submitted PoC

Documentation does not indicate that a
complete inspect was conducted and the
annual inspection failed to find and abate
the deficiencies cited under K056.

Documentation (dated 1/13/09) for an
annual sprinkler inspection indicates four
pages of deficiencies that have not been
corrected during the past two years

(New 10/22/09): The documentation
of testing and maintenance that was
available on site fails to address the
deficiencies statements above.

10/22/09: The sprinkler documentation of 1/13/09 and 4/29/09 contains numerous asterisks and references an addendum for each report. The provider was unable to explain the asterisks on each report and failed to provide the addendum, after repeated requests from the surveyor.

5/12/10: The PoC lacks an item-by-item response for each of the above deficiencies.

3) Modified 5/12/10: Dry Pipe sprinkler systems - Loading Dock: The documentation dated 2/23/10, fails to identify the annual "trip" test and/or the full trip test this is required every three years. The date of the last full trip test is not documented

a) Corrected 10/22/09

b) Corrected 10/22/09

4) Four Pre-action Dry Pipe systems - multiple systems - identify each:

a) The provider lacks documentation for
each system that indicates an annual
inspection of each system was conducted
including the internal inspections that are
required under 9-4.3.1.3 and 9-4.3.1.4.

5/12/10:
The forms dated 4/29/09 are more than
one year old. The forms are not
completely filled out and some required
testing is marked "NA".

b) Documentation testing in accordance
with 9-4.3. is not
available for each system.

c) Documentation of testing of the fire
alarm components for each system is not
available.

The provider failed to correct the above
items in accordance with the last
submitted PoC.

5) Anti-freeze systems:

Annual testing indicates that three of three
anti-freeze systems have been tested for the
last two years and the specific gravity for
each
system tests well above the expected winter
ambient temperatures for each of the three
systems.

There is no indication that this was corrected.
There is no documentation that indicates that
the entire system (each system) has been
inspected and that some or all of each
system
is not damaged by freezing.

10/22/09: The provider failed to correct the above item in accordance with the last submitted PoC.

5/12/10: The provider failed to correct the above item in accordance with the last submitted PoC.

6) Corrected 5/12/10

A) From random observation the surveyors find that HVAC Equipment Rooms are open to shafts.

1) The Basement Level Machine Room (1963 Bldg) is open to and is unseparated from one duct shaft at the northwest corner of the room and another that is south-center of the room.

5/12/10: The Life Safety Plans identified in the last submitted PoC, to be provided by 3/31/10, were not available on site.

a) With the machine room open to vertical
shafts that are three stories or less the
room is required to be enclosed to one
hour fire rated construction as a vertical
(shaft) enclosure.


b) Corrected 10/21/09

c) Multiple duct penetrations penetrate of
this room and lack fire dampers in
accordance with NFPA 90A (example:
ducts from AC-1) (required because it is
part of a shaft enclosure).

d) Deleted 5/25/11

e) Corrected 10/21/09

2) Corrected 5/25/11

3) From random observation, the surveyors find that fire dampers are not installed and maintained in accordance with NFPA 101, chapter 8 and with NFPA 90A:

a) The provider lacks accurate information
regarding the location of every fire
damper and how to get to it (including
where the fire damper access panel is
located).

b) Corrected 5/25/11

c) In some locations fire dampers are
installed; however no fire damper access
panels are provided. In some areas the
access panel does not provide access to
the fire damper (too small or too far from
the damper).

d) In some locations, fire dampers are not
installed in accordance with NFPA A
90A and the damper manufacturer's
specifications. This includes dampers
that are installed using intumescent caulk
and fire dampers that are installed
without retaining angles. (example: 1st
Floor Exist Passageway for the
Southwest Stair, at Dietary)

e) A number of locations where fire
dampers were installed have access
panels with labels that indicate that the
fire damper was removed (or disabled)
in 2001, 2002 or 2003. This condition
was observed throughout the facility.
The surveyors observed that the
dampers were removed or disabled in
locations where fire dampers are
required. (example: 1st Floor Exist
Passageway for the Southwest Stair,
at Radiation Oncology and at Dietary)



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B) It could not be demonstrated either through direct observation or staff interview that the existence of fire dampers and protections are provided for the duct penetrations of supply and return/exhaust ventilation systems originating in the fifth floor mechanical room. (NFPA 90A, 1999, 3-3.2 & 3-3-4.4).



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C) The surveyor from direct observation that the ventilation duct penetrations serving the induction ventilation units on most if not all wings, on multiple floors are not protected with fire dampers in accordance with NFPA 90A, 3-3.4. Surveyor observed flexible duct work penetrating the fire resistant floor construction to the unit above without fire dampers or means of compliance with NFPA 90A. Each floor containing induction units with through floor penetrations failed to maintain the floor/ceiling assembly as a two hour fire rated assembly.

The last submitted PoC indicates that the referenced systems comply with the 1965 Edition of NFPA 90A. However, not enough information is included to substantiate this condition. A cross section sketch that shows the floor penetration, the unit ventilator above, the feed from a larger duct below or from a vertical riser (with the fire rating of a shaft around the riser and a fire damper) and the type of materials used, was not included in the PoC.

The item still requires a correction date in the far right column or needs to indicate in that column that correction is not required.

The surveyor finds a number of fire dampers that are not installed in accordance with NFPA 90A.

A.) A duct penetration through a designated 2 hour fire resistant floor assembly was observed that, due to the lack of fire damper, allowed the passage of smoke and fire between floor levels. Surveyor observed the duct extending through only one floor. This condition does not comply with NFPA 90A 1999 3-3.2. Location observed:

Basement level, return air duct in the air handling mechanical room for the Manor bldg.

10/22/09 - The above item was not corrected in accordance with the last submitted PoC.

A) 1) Corrected 12/28/10.

a) Corrected 12/28/10.

i) Corrected 12/28/10.
ii) Corrected 5/12/10
iii) Deleted 10/22/09

2) The above referenced cooking line, hood system and hood suppression system (1st Floor Main Kitchen) are not tested, serviced and maintained, semi-annually in accordance with NFPA 13 and NFPA 96:

a) The Kitchen Hood and Hood Suppression
System were not re-certified when the
appliance under the hood changed.

b) Testing documentation from an outside
contractor dated 3/11/09 indicated that
system was operational and the "nozzles
are correctly positioned. The nozzles
were not installed in accordance with the
suppression manufacturer's
specifications.

c) Testing, service and maintenance
documentation was incomplete:

i) Documentation for semi-annual
inspection, testing and maintenance was
not found. The most recent report for
2010 was not available on site.

ii) The documentation does not identify
testing that was conducted to confirm
that the fuel sources for ALL appliances
under the hood shut off upon activation
of the system.

5/12/10: The last available onsite
documentation, indicates
that the are only gas fired appliances
under the Kitchen Hoods and they have
been tested and perform in accordance
with the referenced standards. However,
there is a tilt skillet with hood
suppression above it. This appliance is
electrically fueled. There is no
evidence indicates that: there is an
automatic shut off for this appliance, that
it has been tested and that it compliance
with NFPA 13/17/96.

iii) Duct cleaning - Corrected 10/22/09

iv) No documentation is provided to
indicate whether this system complies
with U L 300 in accordance with
7-2.2 of NFPA 96 - 1998

v) The documentation does not
indicate that activation of the system actives
the building fire alarm system.

vi) Corrected 5/12/10

05/12/10: Corrections were not completed in accordance with the last submitted PoC. The provider terminated interim life safety measures without correcting the deficiencies cited.

a) Semi-annual testing, maintenance and inspection in accordance with NFPA 96 was not performed semi annually.

b) Corrected 5/12/10

The above citations will not be cleared until till full documentation of two semi-annual inspections (that indicate full compliance) are found. The current arrangement of sprinkler nozzles above the ranges (partially obstructed by shelves) does not comply with NFPA 13 - 1999 (5-6.5.1.2). The surveyor recognizes that the misting head sprinkler suppression system is a specialized system however, the provider lacks evidence of how this system complies and why the sprinkler heads referenced are not obstructed.

3) The Kitchen or Servery Cooking areas were recently modified to include that addition of an outside make up air fan. The provider indicates that this system has not worked properly since it was installed. The provider lacks documentation of testing that indicates that the existing systems provide adequate make up (replacement air) in accordance with 5-3 of NFPA 96.

An air balance report for this system is not available on site.

5/12/10: the above item was not corrected in accordance with the last submitted PoC.


4) (New 10/22/09): The 1st Floor Cafeteria Serving Area has three Kitchen Hoods with ANSUL Suppression Systems. These three systems are not tested, serviced and maintained in accordance with NFPA 17A and NFPA 96.

a) Corrected 5/12/10

b) Three separate, individual, ANSUL Systems are provided. Which hood is served by each ANSUL system is not clearly identified. 5/12/10: The hoods and pull stations are clearly identified; however, the three ANSUL systems lack clear identification as to which hood is served.

c) Deleted 5/12/10

d) (Modified 5/12/10): Gas fire equipment is installed at two hoods (one w/ four fryers and one with a char grill and a flat grill). The third hood has electrically fueled hot plates. The location of the automatic gas shut off valve for the four fryers is not known. 5/12/10: There was no PoC for this item and the provider still is unable to identify the automatic gas shut off valve for two hoods with gas fired appliances.

Based upon the semi-annual testing documentation dated 5/12/10, two of three hoods lack automatic fuel shut off (gas) upon activation of the hood suppression system for each hood in accordance with NFPA 17A and NFPA 96.

The surveyor required the following on 5/12/10 - The appliances under the deficient hoods may not be used until the deficiencies are corrected, tested and documented by a third party qualified technician, indicating the each system complies with NFPA 17A and NFPA 96.

e) Corrected 5/12/10

f) (New 5/12/10): Two of three kitchen hoods in the 1st Floor Servery had grease filters that were improperly re-installed. The provider removes the filters for cleaning but failed to re-install the filters for two hoods such that there were no gaps, open joints, etc. that allow grease to by-pass the filters.

5) (Modified 5/12/10) Given the lack of documentation of semi annual maintenance and testing (Repeat Deficiency) and given the failure to implement and complete corrective actions in accordance with the last submitted PoC, enhanced interim life safety measures are required until all items are corrected.

5/12/10: The large ABC extinguisher in the main Kitchen in inappropriate for the type of fires that occur in a kitchen area and does not comply with NFPA 10.



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A) Corrected 5/12/10

A) From random observation, the surveyors find that trash and line chutes do not comply with NFPA 82:

1) The Basement Level Linen Chute Discharge Room
a) Corrected 5/12/10
b) Corrected 5/12/10

c) Six ducts penetrate the walls of the Linen Chute Discharge Room. Two of
the ducts appear to penetrate the trash chute enclosure. Six of six ducts lack
fire dampers in accordance with NFPA 90.
(UPDATE 5/24/11) currently 4 of the 6 ducts have dampers installed as part of the facility wide installation.

d) Deleted 10/22/09


2) Corrected 5/25/11
3) Corrected 10/22/09
4) Corrected 5/25/11
5) Corrected 5/25/11

A) 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. For example furnishings and equipment were observed stored in 8'-0" wide exit access corridors. These objects obstruct paths of egress which does not comply with 19.2.3.3. and 7.1.10.2.2. Locations observed:

1. 3rd floor corridor surrounding the
Surgery suite - numerous carts,
equipment, containers of combustible
materials covered in plastic were
observed for the length of the corridors.

2. 4th floor C-Section area - contained
furniture and equipment, including a
couch.

B) Corrected 5/24/11
C) Corrected 5/12/10
D) Corrected 5/24/11




.

A) Based on direct observation, the facility failed to provide:

An intervening corridor wall between the medical gas zone control valves and the outlets and inlets they serve at the following locations (NFPA 99, 1999, 4-3.1.2.3 (d)

a. Emergency Room

b. 11th Floor Dialysis



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B). The Surveyor finds that manual medical gas shutoff (zone) valves were located in the same room as the station outlets and inlets they serve which does not comply with NFPA 99 1999 4.3.1.2.3.(d).
Locations observed:

1. Third Floor - Each O.R. contains the
shut off valve for Nitrious and Oxygen.
Each valve is located within the O.R.'s
adacent to the door between the sterile
core and the O.R.'s.

2. Corrected 5/25/11


C). Corrected 12/28/10.




.

A. Interim Life Safety Measures: 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.

1) Corrected 05/24/11

B) Corrected 05/12/10

A. Interim Life Safety Measures: 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.

A) (Modified 5/12/10): Based upon observation the Dietary elevator lacks automatic recall in accordance with ANSI A17.3.

1) (New 5/12/10): The surveyor finds that (under any condition including fire alarm activation) the elevator doors on one or both sides of the elevator staff open indefinitely on any floor unless a button is pushed inside the car to close the doors.

B) Corrected 5/12/10
C) Corrected 5/24/11