HospitalInspections.org

Based on observation the means of egress do not comply with the requirements for exit access corridors. Uncontrolled activity and use areas open to corridors without protection could result in a fire and could delay evacuation of patients in an emergency.

Findings include:

1. At 2:15PM on March 13, 2015, with the DOF, VPOF and SO in attendance the surveyor finds that the ground floor lab waiting area is open to the exit access corridors. It has smoke detection and is supervised only until 7:00PM. It lacks sprinkler protection in accordance with exception # 1 under 19.3.6.1.

2. The main entrance lobby has been evaluated as part of the 1st floor because the glass wall between the entrance level and the 1st floor level is a corridor wall which is smoke tight only and not fire rated. The surveyor also notes that this lobby is separated from the ground floor level by two-hour fire barriers. At 1:45PM on March 13, 2015, with the DOF present the surveyor observed that the main entrance lobby is also a waiting area which is part of a means of egress. It has smoke detection and sprinkler protection per 19.3.6.1. However, the smoke detectors are too far from the perimeter walls and the spacing for the smoke detection does not comply with NFPA 72.

3. At 11:45AM on March 13, 2015, with the DOF in attendance, the surveyor observed that the 1st floor exit access corridor running from the gift shop, east to the two- hour fire barrier between Building A and Building C and south into the admitting suite has a plenum ceiling return air system. The corridor walls have plenum return air openings above the ceiling and the corridor ceilings have plenum return are louvers (without ductwork). The two-hour fire barrier between Building A and Building C, above the ceiling was observed to have a plenum return air opening with a fire damper. A smoke damper in the same opening above the ceiling and a smoke detector within five feet of the opening above the ceiling was not found. According to the DOF there are similar openings in the corridor wall. Complying smoke dampers with smoke detectors were not found. The documentation for 6 year testing of fire and smoke dampers for 2009 was also reviewed with the DOF. Smoke dampers in the 1st floor corridor walls by location were not found. Based on the above, the surveyor finds the 1st floor corridor walls are not smoke tight to the deck above in accordance with 19.3.6.2.1. The extent of the plenum return air system was not determined.

Based on observation, the surveyor finds the provider lacks complying corridor doors.

Findings include:

1. At 2:35PM on March 13, 2015, with the DOF, VPOF and SO present, the surveyor observed the corridor door to the ground floor construction storage rooms (two rooms) was taped such that the latchset would not latch in accordance with 19.3.6.3.

Based on observation, the surveyor finds that the provider lacks protected vertical openings. Failure to maintain shaft enclosures could result fire spreading floor to floor in a fire emergency.

Findings include:

1. At 12:45PM on March 12, 2015 with the DOF present, the surveyor observed a 4th floor (CPD) shaft access door which was locked. The DOF was not able to provide access for inspection. The surveyor deems this shaft has deficiencies and does not comply with 19.3.1.

2. At 1:15PM on March 12, 2015, with the DOF present, the surveyor observed the shaft enclosure in the ground floor Radiology Reception Room has a large void in the wall above the duct penetration. The shaft is open to the ceiling cavity of the room and does not comply with 19.3.1.

3. At 3:00PM on March 12, 2015, with the DOF present, the surveyor observed a shaft enclosure in the 4th floor Same Day Surgery Waiting Room. A duct in the shaft appeared to penetrate the shaft wall without a fire damper and without a fire damper access panel. The duct penetration above the ceiling on the outside of the shaft appeared to be a much larger lateral duct which was imbedded into the shaft wall. The shaft wall was not constructed to comply with 19.3.3.1 and a fire damper was not found in accordance with NFPA 90A.

Based on observation of door functions and testing of the fire alarm system, the surveyor finds that doors with hold open devices and doors with automatic open functions do not comply. This condition could allow fire and smoke to spread beyond the location of fire origin

Findings include1. Between 1:45PM and 2:00PM on March 13, 2015, with the DOF present during fire alarm testing the surveyor observed that doors which are designated fire doors, smoke door and/or doors to hazardous areas do not comply with 19.2.2.6 and 72.1.8.

Locations include

a. 4th floor Same Day Surgery - all pairs of automatic openings corridor doors.

b. 4th floor Elevator Foyer AA - pair of fire doors with hold open devices.

c. 4th floor pair of smoke doors to the ICU have automatic openings features which are not disabled from fire alarm activation.

d. All doors with automatic openings features which are not disabled from fire alarm activation on the 2nd floor (surgery, PACU, soiled utility etc.)

e. Based on the above observations, the surveyor expects to find that all doors with automatic openings features are not disabled from fire alarm activation.

f. At 2:00PM on March 13, 2015, with the DOF present, the surveyor observed two of two 90-minute fire doors between the cafeteria and kitchen on magnetic hold open devices failed to close upon activation of the fire alarm system in accordance with 7.2.1.8. These doors are part of the fire separation between Building B and Building C. The surveyor observed the pair of auto-open corridor doors to the cafeteria (same fire area) failed to disable and close upon activation of the fire alarm system in accordance with 19.3.6.3.2 and 19.7.2.1.


2. Between 1:30PM and 2:00PM on March 13, 2015, with the DOF present during fire alarm testing, the surveyor observed that corridor doors and doors to designated suites do not comply with 19.3.6.3.2 and 19.7.2.1.

Findings include:

a. 3rd floor pair of cross corridor doors to the OB suite have automatic opening features which are not disabled from fire alarm activation.

b. The ground floor pair of automatic opening corridor doors to the cafeteria were not disable upon activation of the fire alarm system

Based on observation, personnel interview and a review of plans dated 03/09/15, the surveyor finds the required smoke barriers are incomplete. Failure to install and maintain smoke compartmentation could delay patient evacuation to a complying compartment in a fire emergency,

Findings include

1. The locations and boundaries for smoke compartments are identified on the plans dated 03/09/15; however, based on a review of the plans with the DOF in attendance the surveyors finds the line quality and symbol used to identify smoke barriers is very difficult to read and the identification of smoke compartment boundaries and size is not clearly delineated. This made compliance with 19.3.7.1 and 19.3.7.3. difficult to confirm.

2. At 2:30PM on March 12, 2015, with the DOF in attendance, the surveyor observed a 4th floor designated smoke barrier in SPD. The wall above the ceiling had unsealed holes and cable penetrations; the wall was not smoke tight in accordance with 19.3.7.1 and 19.3.7.3.

3. At 4:15 PM on March 12, 2015, with the DOF in attendance, the surveyor observed a 3rd floor designated smoke barrier near the nursery with a 12" x 12" void in the wall above the ceiling; the wall was not smoke tight in accordance with 19.3.7.1 and 19.3.7.3.

4. At 11:00AM on March 13, 2015, with the DOF in attendance, the surveyor observed at a 1st floor pair of doors near Room 112. The designated smoke wall above the ceiling had unsealed cable penetrations; the wall was not smoke tight in accordance with 19.3.7.1 and 19.3.7.3.

5. At 11:05AM on March 13, 2015, with the DOF in attendance, the surveyor observed a pair of designated smoke doors near speech pathology with unsealed cable penetrations above the ceiling; the wall was not smoke tight in accordance with 19.3.7.1 and 19.3.7.3.

6. At 2:35PM on March 13, 2015, with the DOF in attendance, the surveyor observed a ground floor pair of doors near bone density, the designated smoke wall above the ceiling had unsealed cable penetrations; the wall was not smoke tight in accordance with 19.3.7.1 and 19.3.7.3.

Based on observation hazardous areas are not properly enclosed. Failure to isolate hazardous areas from all other areas could allow fires to spread beyond the rooms with larger fuel loads and compromise exit paths.

Findings include

1. At 2:00PM on March 12, 2015, with the DOF, the VPOF and the SO in attendance, the surveyor observed the kitchen in Building C ground floor is also used as a storage area (storage areas are open to the kitchen and dish washing areas). This constitutes a hazardous area. The surveyor observed that the pair of doors from the corridor to the dish washing area lacked positive latching hardware in accordance with 8.4.1. to protect the corridor from a hazardous area.

2. At 4:00PM on March 12, 2015, with the DOF in attendance, the surveyor observed the 2nd floor elevator lobby of Building C is open to the exit access corridor. The north end of the lobby was used to store construction materials and lacked a smoke tight enclosure in accordance with 39.3.2 and 8.4.1.

3. At 4:05PM on March 12, 2015, with the DOF in attendance, the surveyor observed the 2nd floor TV storage room corridor door was held open by wedging the door handle under a shelf. This condition does not comply with 7.2.1.8

Based on observation, the surveyor find that hazardous areas are not properly enclosed to protect other areas of the building. This condition will allow a fire in a hazardous area to spread unchecked to other areas of the building.

Findings include

1. At 11:30AM on March 12, 2015, the surveyor observed with the DOF present the basement level Phone Room is a large storage space which lacks a 3/4-hour fire rated, self closing door in accordance with 19.3.2.1.

Based on a review of plans dated 03/09/15 and observation, the facility failed to provide a protected path to a public way from required exit stairs. Failure to maintain required exits could result in loss of an exit path or delay of evacuation in an emergency.

Findings include:

1. At 11:40AM on March 12, 2015, with the DOF, the VPOF and the SO in attendance, the surveyor found the northwest stairs of Building C serves as a required exit for floors 2 through 4. The stair discharges into the 1st floor main lobby of Buildings A and B. The stair continues to the basement level. The DOF indicates the basement corridor is part of an exit enclosure; however, it is not identified on any plans as an exit passageway and the level of exit discharge is identified with an exit sign in the stair as the 1st floor lobby.

The surveyor finds from document review of plans dated 03/09/15, with the DOF in attendance, this exit stair is the only exit stair which is accessible from the 4th floor exit access corridor. Another exit stair which is accessible from other floors, Building C south stair, has a direct discharge to the outside. There is no complying exit access path to Building C south stair from the 4th floor. The surveyor finds the provider is not able to demonstrate how the Building C northwest stair complies with 7.7.1 and/or 7.7.2. The surveyor finds the exit discharge into the 1st floor lobby does not comply with 7.7.1. and that this exit path cannot comply with 7.7.2 because it is the only exit from the 4th Floor and therefore must discharge in accordance with 7.7.1. The surveyor also notes the ground floor of this building is not sprinklered and there are two elevator door openings in the ground floor corridor, described by the DOF as a possible exit enclosure. Lack of sprinkler protection means the stair cannot comply with 7.7.2. The elevator doors openings are not permitted within an exit enclosure under 9.4.6.
Based on the above, the exit discharge does not comply with 7.7.2 or 7.7.2

2. At 11:45AM on March 12, 2015, with the DOF, the VPOF and the SO in attendance, the surveyor observed the level of exit discharge for Building C northwest stair is identified as the 1st floor; however, the stair continues down to the basement level and lacks an interrupter gate or other effective means to restrict travel below the level of exit discharge in accordance with 7.7.3.

4. At 11:50AM on March 12, 2015, with the DOF, the VPOF and the SO in attendance, the surveyor determined these exit stairs have hand railings with open ends and which lack railing terminations in accordance with 7.2.2.4.5 (5).

Based on a review of plans dated 03/09/15 and observation, the surveyor finds that a required exit stair lacks a protected path to a public way. Failure to maintain required exits could result in loss of an exit path or delay of evacuation in an emergency.

Findings include:

1. At 12:00PM on March 12, 2015, with the DOF present, the surveyor observed a stair from Building C penthouse which discharges into a 4th floor Building C corridor via the elevator foyer for Elevator B. This stair is only one of two exit paths off of the roof and mechanical penthouses and the stair lacks an exit discharge in accordance with 7.7.1 or 7.7.2

2. On March 12, 2015 and March 13, 2015, with the DOF present, the surveyor observed that multiple required exit stairs and other "change of level" steps have hand railings with open ends which lack railing terminations in accordance with 7.2.2.4.5 (5).

a. This includes all railings in the Building A Northeast Exit Stair.

b. This includes all railings in the Building A southwest Exit Stair

c. Both hand rails at the steps and at the change in level in the corridor between the main lobby and the lab waiting area.

d. Both handrails at the steps from the 1st floor upper lobby to the South Parking Lot.

3. At 1:45 PM on March 13, 2015, with the DOF present, the VPOF and SO in attendance, the surveyor observed the exit discharge for the Building B center stair discharges into a ground floor space with two elevator door openings. The space is identified by the DOF as an exit enclosure with a door directly to the outside. It is identified on the plans with a two-hour fire rated enclosure; however, it is not identified as an exit passageway. The location cannot serve as an exit enclosure in accordance with 7.7.1; it does not comply with 9.4.7 which does not permit an elevator door in an exit enclosure.

Based on the above findings the surveyor finds that the provider is not able to demonstrate how the Building B center stair complies with 7.7.1 or 7.7.2 of NFPA 101 - 2000.

4. Based on observation at 1:40PM on March 13, 2015, with the DOF present, the surveyor finds Building B center stair lacks an interrupter gate or other effective means to restrict travel below the level of exit discharge in accordance with 7.7.3.

5. At 2:00PM on March 13, 2015, with the DOF present, the surveyor observed that three of three required exit stairs which serve a pediatric floor in Buildings A & B have handrails which are spaced apart 20" or more (vertically) and which exceed the 4" ball rules under 7.2.2.4.5.

6. Based on observation with the DOF present, over March 12 and March 13, 2015, the surveyor finds that three of three exit stairs in Building A and B and three of three exit stairs In Building C and D lack signs which clearly identify the exit stair with a unique identification label in accordance with 7.2.2.5.4. (example: although the Building A Northeast exit stair is identified verbally by the provider as "Stair A Northeast", there is no label inside the stair which includes this information and/or any information which allows that stair to be uniquely identified.

A. Based on direct observation, the surveyor finds an exit access was obstructed and an on-going project created deficiencies. The provider failed to implement interim life safety measures. Failure to implement and maintain adequate interim life safety measures could result in a fire, delayed response from life safety systems and staff, and could delay patient evacuation in an emergency.
.
Findings include:

1. At 1:15PM On March 12, 2015, with the DOF, VPOF and SO present, the surveyor observed a 2nd floor patient corridor which was obstructed by a temporary visqueen construction barrier creating a dead end corridor on both sides of the construction zone. Temporary exit signs and posted temporary evacuation plans were not provided. Adequate interim life safety measures were not found for this condition in accordance with 4.6.10 of NFPA 101 and NFPA 241.

Deficiencies included:

a. The visqueen used lacked an interior finish rating as a Class A, B, or C interior finish in accordance with 19.3.3.1.

b. Construction personnel were using a portable hand torch on the floor. A fire extinguisher and a dedicated fire watch were not found for this condition in accordance NFPA 241. The provider lacks a "hot work" or " burn permit" process as part of the facilities interim measures so the no cutting, welding, grinding or other hazardous construction activities can occur in the hospital without the provider's knowledge and documented permission, in accordance with NFPA 241.

B. Based on observation throughout the facility, the surveyor find doors which are identified as exits have delayed egress locking without the signs which are required. Other door deficiencies were also observed.

1. On March 12 and 13, 2015, with the DOF present, the surveyor observed, doors to exits and exit paths which are marked with exit signs have magnetic locking devices which do not have signage in accordance with 7.2.1.6.1.

Examples include but are not limited to


a. 2nd floor pair of designated smoke doors between Building A and Building B

b. 2nd floor door to Stair A Southwest

c. 3rd Floor door to Stair A Northeast

d. 3rd floor pair of doors Elevator Foyer AA

e. 3rd floor corridor door near Stair A Southwest.

f. 3rd floor door to the Building B center stair has magnetic locking device which lacks a sign. During testing by the surveyor at 3:10 PM with the DOF, VPOF and SO present, the surveyor found the doors took well in excess of 15 pounds of force to initiate the releasing action. [7.2.1.6.1 (c)]

2. At 3:15PM on March 13, 2015, with the DOF present, the surveyor observed one leaf of a pair of storage room doors in the kitchen had a single cylinder dead bolt lock which does not comply with 7.2.1.5.

3. At 3:00PM on March 13, 2015, with the DOF present, the surveyor observed that a pair of power operated sliding alum/glass doors in the emergency department's means of egress is equipped with a break and swing function. The doors lack a sign "In emergency push to open" in accordance with 7.2.1.9.

Based on observation, the surveyor finds the two-hour fire barriers are not constructed as two-hour barriers or have voids and penetrations which are not sealed for two-hour construction. Failure to maintain fire barriers could result in the spread of fire and smoke beyond the room of fire origin.

Findings include:

1. At 12:35PM on March 12, 2015, with the DOF, VPOF and SO in attendance, the surveyor observed the designated two hour barrier (masonry wall) between Building A and Building C at the 4th floor had a cable penetration which was not sealed for two-hour construction in accordance with 8.2.3.2.4.

2. At 11:45PM on March 13, 2015, with the DOF, VPOF, and SO in attendance, the surveyor observed the designated two-hour barrier (masonry wall) between Building A and Building C at the 1st floor had a cable penetration which was not sealed for two-hour construction in accordance with 8.2.3.2.4

Based on observation, the facility failed to maintain fire barriers. This could result in the spread of fire and smoke beyond the room of fire origin.

Findings include:

1. At 12:10 on March 13, 2015, with the DOF in attendance, the surveyor observed the designated two-hour barrier between Building C and Building D is not continuous from outside wall to outside wall. The fire barrier has no continuity in accordance with 7.2.4.3. The wall construction above a pair of cross corridor doors (a designated two-hour barrier) was observed to be one layer of drywall with voids. This condition is not considered two-hour construction as indicate on the plans dated 03/09/15. This locations is part of the continuous two hour barrier on all floors which separates Building C vertically from Building D.

Based on direct observation, the surveyor finds the emergency lighting with battery back up is not installed where required. This condition could result in complete and total darkness until lighting connected to the emergency generator comes on during a power failure.


Findings include

1. At 4:00PM on March 12, 2015, with two obstetrical nurses in attendance, the surveyor determined that the 4th floor C-section room lacks emergency lighting with battery back up in accordance with NFPA 99-1999, 3-3.2.1.2(a)5(e).

A. Base on direct observation, the surveyor find the ground floor, 1st floor and 2nd floor have required exit paths through a two-hour fire barrier into the corridors of Building C & D. These exit paths are identified on plans dated 03/09/15 as two-hour fire barriers and as two-hour occupancy separations. These exit paths are not identified on plans as a horizontal exit. The lack of correct designation could delay patient evacuation in an emergency.

Findings include:

a. March 12 and March 13, 2015, with the DOF, VPOF and SO in attendance, the surveyor observed these exit paths are not identified on plans as horizontal exits. This information is critical for the correct evaluation of Buildings A, B, C and D.

b. March 12 and March 13, 2015, with the DOF, VPOF and SO in attendance, the surveyor observed the above exit paths lack an illuminated exit sign on two of three floor levels (ground and 1st floor) in accordance with 7.10.1.

3. At 1:00PM on March 13, 2015, with the DOF, VPOF and SO in attendance, the surveyor observed the 5th floor roof extends across the Buildings A, B and C and has four or five mechanical penthouses and several elevator penthouses. None of the penthouses and no portion of the roof had any illuminated exit signs identifying the path to an exit in accordance with 7.10.1.

4. At 12:50 on March 13, 2015, with the DOF, VPOF and SO in attendance, the surveyor observed the 5th Floor Building C penthouse has an exit sign which was not illuminated and was mounted perpendicular to the wall such that it was not visible from most of the space.

B. Based on observation the surveyor finds illuminated exit signs are not provided correctly . This could delay patient evacuation in an emergency.

Findings include:

1. At 2:40PM on March 13, 2015, with the DOF in attendance, the surveyor observed the ground floor Emergency Department lacks an illuminated exit sign identifying the second path of egress from this area, in accordance with 19.2.10.1

Based on observation, the facility lacks proper illuminated exit signs. This could result in the delay of evacuation in a fire emergency.

Findings include:

1. At 11:45 AM on March 12, 2014, with the DOF, the VPOF and the SO in attendance, the surveyor observed a 4th floor vacant occupational health suite is located on the south half of Building C, lacks illuminated directional exit signs identify the exit path through a complicated arrangement of halls and rooms, in accordance with 39.2.10. This suite has access to an exit access corridor to the north and to the south east stair of Building C.

Based on a review of the life safety plans, dated 03/09/15, with the DOF at 9:00AM on March 12, 2015, and observation between the March 12 and 13, 2015 on multiple floors of the hospital, the surveyor finds the information provided on the above referenced plans is not accurate. This could affect the patients, visitors and staff evacuating the facility in the case of an emergency.

Findings include:

1. The plans indicate an exit stair from the south end of the roof of Building A. No exit stair was found from this part of the roof.

2. The exit stairs discharge into a corridor-like space which also has a two-hour enclosure. These spaces are not identified as exit passageways on the plans and the exit discharges do not comply unless they are exit passageways. The level of of exit discharge shown on the plan for two exit stairs is not in compliance.

3. A two-hour fire separation is identified on the plans between Building B and Building C. This barrier is also identified as an occupancy separation on the plans. The exit access corridor on the 2nd floor has an illuminated exit sign above the pair of 90-minute doors directing an exit path from Building B into Building C. The 1st floor and ground floor both have similar corridors where an exit path is required into Building C. Building C can be evaluated as a business occupancy and not health care if the two-hour fire barrier complies with the requirements of 19.1.2.4 as a horizontal exit. These two barriers are not identified as horizontal exits. The surveyor also note these two-hour barriers are required smoke barriers at this location on every floor

4. The lines used to identify smoke barriers on the plans date 03/09/15 are difficult to read. This makes it difficult to confirm the size of smoke compartments and travel distances to smoke doors.

5. Although two-hour fire barriers were observed on most floors between Building C and Building D, the surveyor observed that they do not continue through the kitchen on the ground floor between Building C and Building D; therefore, Building C and D have been evaluated as the same building. A two-hour fire separation is not identified on the plans dated 03/09/15 between Building D and an adjacent residential occupancy; however a two-hour fire separation and a 90-minute fire door was observed at this location with the DOF present. The plans are not accurate.

Based on observation and document review, the facility failed to maintain the fire alarm systems in accordance with the code. This could result in a failure of the fire alarm system in a fire emergency.

Findings include:

1. At 10:00 AM, on March 12, 2015, the surveyor along with the DOF, surveyed the Midtown Health Center. The surveyor requested documentation, quarterly, semi-annually and annual testing, maintenance and service documentation for the building's fire alarm system. The DOF indicated no documentation was available for this building, therefore, the surveyor finds the fire alarm system is not tested, serviced and maintained in accordance with NFPA 72 - 1999.

Based on observation and document, the facility failed to maintain the fire alarm systems in accordance with the code. This could result in a failure of the fire alarm system in a fire emergency.

Findings include:

1. At 10:30 AM, on March 12, 2015, the surveyor along with the DOF, surveyed the Midtown Plaza. The surveyor requested documentation, quarterly, semi-annually and annual testing, maintenance and service documentation for the building's fire alarm system. The DOF indicated no documentation was available for this building, therefore, the surveyor finds the fire alarm system is not tested, serviced and maintained in accordance with NFPA 72 - 1999.

A. Based on observation, the surveyor finds the sprinklered areas are compromised by missing ceiling tiles at lay-in ceilings or by obstructions. These conditions could delay notification of a fire in these spaces and delay evacuation in a fire emergency.

Findings include:

1. At 1:05 PM on March 12, 2015, with the DOF present, the surveyor finds that the 2nd floor rehabilitation storage room has a displaced ceiling tile which does not comply with NFPA 13.

2. At 11:30AM on March 12, 2015, with the DOF present, the surveyor finds the basement level is partially sprinklered. A large switchgear room is used for storage which conflicts with the requirements of NFPA 13 for unsprinklered spaces.

3. At 11:35AM on March 12, 2015, the surveyor observed a large maintenance shop/storage space which was evaluated as a hazardous area. The space is sprinklered; however, sprinkler heads are not installed below ductwork which is wider than 4'-0" in accordance with NFPA 13.

4. At 9:15AM on March 13, 2015, the surveyor observed a missing ceiling tile in the 3rd floor storage room opposite Room 307.

5. At 9:20AM on March 13, 2015, the surveyor observed a missing ceiling tile in the 2nd floor storage room opposite Building B Center Stair.

6. At 4:10PM on March 13, 2015, with the DOF present, the surveyor observed the 3rd floor OB mechanical room had only one sprinkler head which was obstructed. The entire room lacked sprinkler protection in accordance with NFPA 13. This room is identified on plans dated 03/09/15 with a two- hour fire rated enclosure. One of the walls was observed with a 12" x 12' void in it and the mechanical room is open to the adjacent ceiling cavity at this void. The room lacks a draft stop for the sprinkler protection and the adjacent ceiling cavity lacks sprinkler protection in accordance with NFPA 13.

7. At 2:35PM on March 13, 2015, with the DOF present, the surveyor observed that the main lobby entrance vestibule has three bays; only the center bay has a sprinkler head in accordance with NFPA 13.

8. At 3:40PM on March 13, 2015, the surveyor observed in the ground floor construction storage room, which is sprinklered, sprinkler heads are installed at lay-in ceiling height and most of the ceiling tiles are missing. The sprinkler heads are not installed in accordance with NFPA 13 and the corridor walls in this room has have unsealed penetrations. The walls are not smoke tight in accordance with 19.3.6.2.

9. At 3:00PM on March 13, 2015, with the DOF, VPOF and SO present, the surveyor observed a soiled utility room in the 4th floor ICU which has a garden hose hanging out of the ceiling with a leak collection barrier in the ceiling cavity. The ceiling cavity was not protected with a sprinkler system in the cavity in accordance with NFPA 13 requirements for protection of interstitial spaces with combustibles.

B. Based on observation between on March 12 and 13, 2015, with the DOF, VPOF and SO in attendance, the surveyor finds that the facility has a fire pump with static pressure on the system above 100PSI. Sprinkler heads with arm overs or end of branch support in excess of 24" were observed to lacks arm-over bracing at 12" in accordance with 6-2.3.3 of NFPA 13 - 1999.

Locations include but are not limited to:

1. 4th floor ICU

2. 4th floor pain clinic

3. 3rd Floor pediatrics waiting area


C. Based on observation between March 12, and 13, 2015, with the DOF present, the surveyor finds the sprinkler system is not installed in accordance with NFPA 13.

Findings include

1. At 2:00PM on March 13, 2015, with the DOF present, the surveyor conducted a sprinkler flow switch test, using the inspector's test valve in the janitor's closet near Room 225. The janitor's sink overflowed and was not able to handle the water flow from the inspector's test. This condition does not comply with NFPA 13.

The above condition also appears to be cited in the annual sprinkler system documentation for 2013 and 2014. There appeared to be other deficiencies cited in the documentation relative to tamper switches, gauges, valves and something identified as "Pressure: broken" PSI. The provider was not able to provide documentation or evidence identifying when and how these deficiencies were corrected.

Based on observation, the facility failed to maintain and install a proper sprinkler system. This could result in in uncontrolled fire spreading to all portion of the building.

Findings include;

1. At 10:10AM on March 12, 2015, the surveyor observed with the DOF in attendance, the transfer switch room lacked sprinkler protection. The room had a 90-minute fire rated door but the walls above the ceiling do not extend to the deck above as a compliant two-hour fire barriers in accordance with the exceptions for unsprinklered spaces under NFPA 13. The walls stop just above the ceiling.

Based on observation, personnel interview and document review the surveyor finds that the fire pump is not tested and maintained. Failure to test and maintain the fire pump could result in failure during a fire emergency.

Findings include

1. At 3:00PM on March 13, 2015, during document review with the DOF, the surveyor finds the documentation for annual fire pump testing for 2014 does not include the correct sequence of testing on emergency power from an emergency generator in accordance with NFPA 20.

2. At 3:00PM on March 13, 2015, during document review with the DOF, the surveyor finds the documentation of testing of four required monitoring points from the fire pump was not found on the annual fire pump documentation for 2014. Testing by the fire alarm contractor could not be confirmed; no documentation for testing of the fire alarm system was found for 2014.

3. At 3:00PM on March 13, 2015, during document review and interview with the DOF, the surveyor finds the documentation for testing and maintenance of the sprinkler system identifies five year testing as "NA". There is no indication as to when pressure gauges were last tested and when back flow devices were last internally inspected. No documentation observed onsite included five year testing in accordance with NFPA 25.

Findings include:

Based on observation and document review, the facility failed to maintain the sprinkler system in accordance with the code. This could result in a failure of the fire detection system in a fire emergency and the spread of fire, uncontrolled,to all portions of the building.

Findings include:

At 10:00 AM, on March 12, 2015, the surveyor along with the DOF, surveyed the Midtown Health Center . The surveyor observed that the building is sprinklered and requested documentation, quarterly, semi-annually and annual testing, maintenance and service documentation for the building's sprinkler system. The DOF indicated that no documentation was available for this building. The surveyor finds the sprinkler systems is not tested, serviced and maintained in accordance with NFPA 25 - 1999.

1. The lack of quarterly flow testing of sprinkler flow switches which includes the location of each switch and the time from water flow to activation of the fire alarm system.

2. The lacks of documentation for inspection, testing and maintenance of the sprinkler system in accordance with NFPA 25.

Based on document review for testing of fire damper and smoke dampers, the documentation does not comply with the six year testing of dampers. Fail to test and maintained fire and smoke dampers could result in failure and the spread of fire and smoke in a fire emergency.

Findings include:

1. At 4:00PM on March 13, 2015, during document review, the surveyor finds the 2009 documentation identified a significant number of deficient dampers. The surveyor finds that the documentation does not comply with NFPA 90A for six year testing of dampers. A unique identifying number or label is not provided for on each damper, the damper access, and the damper documentation in accordance with NFPA 90A.

2. At 4:00PM on March 13, 2015, during document review, the surveyor finds the location method for identifying specific dampers is vague (examples include multiple designations under "hall" and "chase FSD". Documentation for the combination fire/smoke dampers installed in fire barriers and corridors walls with a plenum return air system at the 1st floor was not found . The surveyor finds the documentation for testing is incomplete and does not demonstrate that all dampers were tested in accordance with NFPA 90A.

Based on observation, the surveyor finds the medical gas systems are not installed and maintain in accordance with code. This condition could result in the loss of medical gas systems during an emergency.

Findings include

1. At 1:00PM on March 13, 2015, the surveyor observed with the DOF present, the temporary construction fence around a temporary mobile emergency generator blocks access to the emergency oxygen fill located on the south side of the hospital. This condition does not comply with NFPA 99 and NFPA 50.

B. At 4:00PM on March 12, 2015, the surveyor observed with the DOF, VPOF and SO present, the 3rd floor C-section hallway had two medical gas shaft valves which were identified for Delivery Room #1 and Delivery Room #2. The DOF indicate the rooms no longer exist. The surveyor finds the labeling of these valves does not comply with NFPA 99 and the valves were not "tagged out" or properly terminated in accordance with NFPA 99.

C. At 2:00PM on March 13, 2015, the surveyor observed with the DOF, VPOF and SO present, the ground floor cardiopulmonary suite has a storage room with 28 oxygen tanks (e tanks). These tanks were not stored in a room designed for oxygen storage and/or they were stored in a room without a clear separation from all combustibles of 5'-0" in accordance with NFPA 99.

Based on observation, the surveyor finds the emergency generators are not installed and maintained in accordance with code. These conditions could result and loss of emergency power during failure of normal power to the facility.

Findings include:

1. At 11:00PM, on March 12, 2015, with the DOF present, the surveyor observed the facility has two emergency generators in the basement level in a fire rated enclosed generator room. One is a new generator under construction which replaced an existing generator in the same location. A 3rd generator is installed on the roof and a 4th emergency generator is a temporary mobile unit installed in the South Parking Lot.

The remote stop for the two generators in the basement lack unique identification to clearly indicate which generator is connected. The temporary mobile generator does not have a remote stop and the emergency stop button installed on the mobile generator is not accessible without delay due to the chain link fence in front of it. These conditions do not comply with NFPA 99 and NFPA 110.

2. At 11:05PM on March 12, 2015, with the DOF, VPOF and SO in present, the surveyor observed the basement level generator room has multiple air intake louvers with fire dampers. One louver was partially blocked off with rigid insulation. The use of this combustible material in front of the fire damper does not comply with NFPA 90 A and the damper manufacturer's installation requirements.

3. At 11:10AM on March 12, 2015, with the DOF present, the surveyor observed construction activity in the generator room with a new generator being installed. Access was restricted by contractors and construction materials including two fifty gallon barrels of hydraulic fluid which are not permitted to be stored in this room under NFPA 99 and NFPA 110. No fire watch was found.

Based on observations and staff interviews during the survey walk-through, March 12-13, 2015, and based on document review, and staff interview, the surveyors find the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

Findings include:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on a review of the documentation the surveyor finds the emergency generators are not documented and tested properly. Failure to test and maintain emergency power systems could result in failure during loss of normal power.

Findings include

1. At 4:00PM on March 13, 2015, during document review with the DOF present, the surveyor finds the documentation for three of three emergency generators identifies only that each is a 250 KVA generator. The documentation does not clearly identify which generator was tested by model numbers, serial number or other unique identification. The documentation also does not clearly identify which transfer switches were used for each test. This documentation does not comply with NFPA 70, NFPA 99 and NFPA 110.

3. At 4:00PM on March 13, 2015, during document review with the DOF present, the surveyor observed a gap in the documentation which indicates no monthly testing occurred between 6/13/14 and 9/26/14. This period for testing does not comply with NFPA 70, NFPA 99 and NFPA 110.

2. At 4:00PM on March 13, 2015, during document review with the DOF present, the surveyor finds the documentation for periodic testing of emergency power transfer switches is incomplete. The documentation for each transfer switch does not clearly identify the date the test was conducted and which generator was used during the test. This documentation does not comply with NFPA 70, NFPA 99 and NFPA 110.

3. At 10:00AM on March 12, 2015 , the surveyor observed a temporary mobile emergency generator in the South Parking Lot and at 4:00PM on March 13, 2015, during document review at with the DOF present, the surveyor finds the provider has no documentation which identifies a weekly visual inspection of this generator in accordance with NFPA 99 and NFPA 110.

Based on observation, the surveyor observed the electrical systems and materials are not installed and maintained. This condition could delay any response during and electrical emergency.

Findings include:

1. At 1:45PM on March 12, 2015, with the DOF present, the surveyor finds in the basement level generator room, access to switchgear was blocked by contractor equipment carts. At least 3'-0" of clear space is not maintained in accordance with NFPA 70.

2. At 2:00PM on March 12, 2015 with the DOF present, the surveyor finds the basement level switchgear, near the assistant manager's office, access was blocked by combustible storage. At least 3'-0" of clear space is not maintained in accordance with NFPA 70.

3. At 2:00PM on March 12, 2015, with the DOF present, the surveyor observed the switchgear for the CT AHU lacked an identifying label on the outside of the panel in accordance with NFPA 70 and access was blocked by storage. At least 3'-0" of clear space is not maintained in accordance with NFPA 70.

4. At 11:35AM on March 12, 2015, with the DOF present, the surveyor observed a large maintenance shop/storage space with electrical panels and switchgear at the far end of the room. Access was blocked by storage in front of the panels. At least 3'-0" of clear space is not maintained in accordance with NFPA 70.

5. At 11:40AM on March 13, 2015, with the DOF present, the surveyor observed a 3rd floor surgical staff lounge with a large table and chairs in front of the electrical panels. Access was obstructed for six of six electrical panels. At least 3'-0" of clear space is not maintained in accordance with NFPA 70.

6. At 11:15AM on March 13, 2015, with the DOF, VPOF, and the SO present, the surveyor observed a blue electrical extension cord hanging out of the ceiling of the corridor wall north of the pharmacy. This extension cord was not installed in accordance with NFPA 70 for a permanent electrical device.

Based on observation the means of egress do not comply with the requirements for exit access corridors. Uncontrolled activity and use areas open to corridors without protection could result in a fire and could delay evacuation of patients in an emergency.

Findings include:

1. At 2:15PM on March 13, 2015, with the DOF, VPOF and SO in attendance the surveyor finds that the ground floor lab waiting area is open to the exit access corridors. It has smoke detection and is supervised only until 7:00PM. It lacks sprinkler protection in accordance with exception # 1 under 19.3.6.1.

2. The main entrance lobby has been evaluated as part of the 1st floor because the glass wall between the entrance level and the 1st floor level is a corridor wall which is smoke tight only and not fire rated. The surveyor also notes that this lobby is separated from the ground floor level by two-hour fire barriers. At 1:45PM on March 13, 2015, with the DOF present the surveyor observed that the main entrance lobby is also a waiting area which is part of a means of egress. It has smoke detection and sprinkler protection per 19.3.6.1. However, the smoke detectors are too far from the perimeter walls and the spacing for the smoke detection does not comply with NFPA 72.

3. At 11:45AM on March 13, 2015, with the DOF in attendance, the surveyor observed that the 1st floor exit access corridor running from the gift shop, east to the two- hour fire barrier between Building A and Building C and south into the admitting suite has a plenum ceiling return air system. The corridor walls have plenum return air openings above the ceiling and the corridor ceilings have plenum return are louvers (without ductwork). The two-hour fire barrier between Building A and Building C, above the ceiling was observed to have a plenum return air opening with a fire damper. A smoke damper in the same opening above the ceiling and a smoke detector within five feet of the opening above the ceiling was not found. According to the DOF there are similar openings in the corridor wall. Complying smoke dampers with smoke detectors were not found. The documentation for 6 year testing of fire and smoke dampers for 2009 was also reviewed with the DOF. Smoke dampers in the 1st floor corridor walls by location were not found. Based on the above, the surveyor finds the 1st floor corridor walls are not smoke tight to the deck above in accordance with 19.3.6.2.1. The extent of the plenum return air system was not determined.

Based on observation, the surveyor finds the provider lacks complying corridor doors.

Findings include:

1. At 2:35PM on March 13, 2015, with the DOF, VPOF and SO present, the surveyor observed the corridor door to the ground floor construction storage rooms (two rooms) was taped such that the latchset would not latch in accordance with 19.3.6.3.

Based on observation, the surveyor finds that the provider lacks protected vertical openings. Failure to maintain shaft enclosures could result fire spreading floor to floor in a fire emergency.

Findings include:

1. At 12:45PM on March 12, 2015 with the DOF present, the surveyor observed a 4th floor (CPD) shaft access door which was locked. The DOF was not able to provide access for inspection. The surveyor deems this shaft has deficiencies and does not comply with 19.3.1.

2. At 1:15PM on March 12, 2015, with the DOF present, the surveyor observed the shaft enclosure in the ground floor Radiology Reception Room has a large void in the wall above the duct penetration. The shaft is open to the ceiling cavity of the room and does not comply with 19.3.1.

3. At 3:00PM on March 12, 2015, with the DOF present, the surveyor observed a shaft enclosure in the 4th floor Same Day Surgery Waiting Room. A duct in the shaft appeared to penetrate the shaft wall without a fire damper and without a fire damper access panel. The duct penetration above the ceiling on the outside of the shaft appeared to be a much larger lateral duct which was imbedded into the shaft wall. The shaft wall was not constructed to comply with 19.3.3.1 and a fire damper was not found in accordance with NFPA 90A.

Based on observation of door functions and testing of the fire alarm system, the surveyor finds that doors with hold open devices and doors with automatic open functions do not comply. This condition could allow fire and smoke to spread beyond the location of fire origin

Findings include1. Between 1:45PM and 2:00PM on March 13, 2015, with the DOF present during fire alarm testing the surveyor observed that doors which are designated fire doors, smoke door and/or doors to hazardous areas do not comply with 19.2.2.6 and 72.1.8.

Locations include

a. 4th floor Same Day Surgery - all pairs of automatic openings corridor doors.

b. 4th floor Elevator Foyer AA - pair of fire doors with hold open devices.

c. 4th floor pair of smoke doors to the ICU have automatic openings features which are not disabled from fire alarm activation.

d. All doors with automatic openings features which are not disabled from fire alarm activation on the 2nd floor (surgery, PACU, soiled utility etc.)

e. Based on the above observations, the surveyor expects to find that all doors with automatic openings features are not disabled from fire alarm activation.

f. At 2:00PM on March 13, 2015, with the DOF present, the surveyor observed two of two 90-minute fire doors between the cafeteria and kitchen on magnetic hold open devices failed to close upon activation of the fire alarm system in accordance with 7.2.1.8. These doors are part of the fire separation between Building B and Building C. The surveyor observed the pair of auto-open corridor doors to the cafeteria (same fire area) failed to disable and close upon activation of the fire alarm system in accordance with 19.3.6.3.2 and 19.7.2.1.


2. Between 1:30PM and 2:00PM on March 13, 2015, with the DOF present during fire alarm testing, the surveyor observed that corridor doors and doors to designated suites do not comply with 19.3.6.3.2 and 19.7.2.1.

Findings include:

a. 3rd floor pair of cross corridor doors to the OB suite have automatic opening features which are not disabled from fire alarm activation.

b. The ground floor pair of automatic opening corridor doors to the cafeteria were not disable upon activation of the fire alarm system

Based on observation, personnel interview and a review of plans dated 03/09/15, the surveyor finds the required smoke barriers are incomplete. Failure to install and maintain smoke compartmentation could delay patient evacuation to a complying compartment in a fire emergency,

Findings include

1. The locations and boundaries for smoke compartments are identified on the plans dated 03/09/15; however, based on a review of the plans with the DOF in attendance the surveyors finds the line quality and symbol used to identify smoke barriers is very difficult to read and the identification of smoke compartment boundaries and size is not clearly delineated. This made compliance with 19.3.7.1 and 19.3.7.3. difficult to confirm.

2. At 2:30PM on March 12, 2015, with the DOF in attendance, the surveyor observed a 4th floor designated smoke barrier in SPD. The wall above the ceiling had unsealed holes and cable penetrations; the wall was not smoke tight in accordance with 19.3.7.1 and 19.3.7.3.

3. At 4:15 PM on March 12, 2015, with the DOF in attendance, the surveyor observed a 3rd floor designated smoke barrier near the nursery with a 12" x 12" void in the wall above the ceiling; the wall was not smoke tight in accordance with 19.3.7.1 and 19.3.7.3.

4. At 11:00AM on March 13, 2015, with the DOF in attendance, the surveyor observed at a 1st floor pair of doors near Room 112. The designated smoke wall above the ceiling had unsealed cable penetrations; the wall was not smoke tight in accordance with 19.3.7.1 and 19.3.7.3.

5. At 11:05AM on March 13, 2015, with the DOF in attendance, the surveyor observed a pair of designated smoke doors near speech pathology with unsealed cable penetrations above the ceiling; the wall was not smoke tight in accordance with 19.3.7.1 and 19.3.7.3.

6. At 2:35PM on March 13, 2015, with the DOF in attendance, the surveyor observed a ground floor pair of doors near bone density, the designated smoke wall above the ceiling had unsealed cable penetrations; the wall was not smoke tight in accordance with 19.3.7.1 and 19.3.7.3.

Based on observation hazardous areas are not properly enclosed. Failure to isolate hazardous areas from all other areas could allow fires to spread beyond the rooms with larger fuel loads and compromise exit paths.

Findings include

1. At 2:00PM on March 12, 2015, with the DOF, the VPOF and the SO in attendance, the surveyor observed the kitchen in Building C ground floor is also used as a storage area (storage areas are open to the kitchen and dish washing areas). This constitutes a hazardous area. The surveyor observed that the pair of doors from the corridor to the dish washing area lacked positive latching hardware in accordance with 8.4.1. to protect the corridor from a hazardous area.

2. At 4:00PM on March 12, 2015, with the DOF in attendance, the surveyor observed the 2nd floor elevator lobby of Building C is open to the exit access corridor. The north end of the lobby was used to store construction materials and lacked a smoke tight enclosure in accordance with 39.3.2 and 8.4.1.

3. At 4:05PM on March 12, 2015, with the DOF in attendance, the surveyor observed the 2nd floor TV storage room corridor door was held open by wedging the door handle under a shelf. This condition does not comply with 7.2.1.8

Based on observation, the surveyor find that hazardous areas are not properly enclosed to protect other areas of the building. This condition will allow a fire in a hazardous area to spread unchecked to other areas of the building.

Findings include

1. At 11:30AM on March 12, 2015, the surveyor observed with the DOF present the basement level Phone Room is a large storage space which lacks a 3/4-hour fire rated, self closing door in accordance with 19.3.2.1.

Based on a review of plans dated 03/09/15 and observation, the facility failed to provide a protected path to a public way from required exit stairs. Failure to maintain required exits could result in loss of an exit path or delay of evacuation in an emergency.

Findings include:

1. At 11:40AM on March 12, 2015, with the DOF, the VPOF and the SO in attendance, the surveyor found the northwest stairs of Building C serves as a required exit for floors 2 through 4. The stair discharges into the 1st floor main lobby of Buildings A and B. The stair continues to the basement level. The DOF indicates the basement corridor is part of an exit enclosure; however, it is not identified on any plans as an exit passageway and the level of exit discharge is identified with an exit sign in the stair as the 1st floor lobby.

The surveyor finds from document review of plans dated 03/09/15, with the DOF in attendance, this exit stair is the only exit stair which is accessible from the 4th floor exit access corridor. Another exit stair which is accessible from other floors, Building C south stair, has a direct discharge to the outside. There is no complying exit access path to Building C south stair from the 4th floor. The surveyor finds the provider is not able to demonstrate how the Building C northwest stair complies with 7.7.1 and/or 7.7.2. The surveyor finds the exit discharge into the 1st floor lobby does not comply with 7.7.1. and that this exit path cannot comply with 7.7.2 because it is the only exit from the 4th Floor and therefore must discharge in accordance with 7.7.1. The surveyor also notes the ground floor of this building is not sprinklered and there are two elevator door openings in the ground floor corridor, described by the DOF as a possible exit enclosure. Lack of sprinkler protection means the stair cannot comply with 7.7.2. The elevator doors openings are not permitted within an exit enclosure under 9.4.6.
Based on the above, the exit discharge does not comply with 7.7.2 or 7.7.2

2. At 11:45AM on March 12, 2015, with the DOF, the VPOF and the SO in attendance, the surveyor observed the level of exit discharge for Building C northwest stair is identified as the 1st floor; however, the stair continues down to the basement level and lacks an interrupter gate or other effective means to restrict travel below the level of exit discharge in accordance with 7.7.3.

4. At 11:50AM on March 12, 2015, with the DOF, the VPOF and the SO in attendance, the surveyor determined these exit stairs have hand railings with open ends and which lack railing terminations in accordance with 7.2.2.4.5 (5).

Based on a review of plans dated 03/09/15 and observation, the surveyor finds that a required exit stair lacks a protected path to a public way. Failure to maintain required exits could result in loss of an exit path or delay of evacuation in an emergency.

Findings include:

1. At 12:00PM on March 12, 2015, with the DOF present, the surveyor observed a stair from Building C penthouse which discharges into a 4th floor Building C corridor via the elevator foyer for Elevator B. This stair is only one of two exit paths off of the roof and mechanical penthouses and the stair lacks an exit discharge in accordance with 7.7.1 or 7.7.2

2. On March 12, 2015 and March 13, 2015, with the DOF present, the surveyor observed that multiple required exit stairs and other "change of level" steps have hand railings with open ends which lack railing terminations in accordance with 7.2.2.4.5 (5).

a. This includes all railings in the Building A Northeast Exit Stair.

b. This includes all railings in the Building A southwest Exit Stair

c. Both hand rails at the steps and at the change in level in the corridor between the main lobby and the lab waiting area.

d. Both handrails at the steps from the 1st floor upper lobby to the South Parking Lot.

3. At 1:45 PM on March 13, 2015, with the DOF present, the VPOF and SO in attendance, the surveyor observed the exit discharge for the Building B center stair discharges into a ground floor space with two elevator door openings. The space is identified by the DOF as an exit enclosure with a door directly to the outside. It is identified on the plans with a two-hour fire rated enclosure; however, it is not identified as an exit passageway. The location cannot serve as an exit enclosure in accordance with 7.7.1; it does not comply with 9.4.7 which does not permit an elevator door in an exit enclosure.

Based on the above findings the surveyor finds that the provider is not able to demonstrate how the Building B center stair complies with 7.7.1 or 7.7.2 of NFPA 101 - 2000.

4. Based on observation at 1:40PM on March 13, 2015, with the DOF present, the surveyor finds Building B center stair lacks an interrupter gate or other effective means to restrict travel below the level of exit discharge in accordance with 7.7.3.

5. At 2:00PM on March 13, 2015, with the DOF present, the surveyor observed that three of three required exit stairs which serve a pediatric floor in Buildings A & B have handrails which are spaced apart 20" or more (vertically) and which exceed the 4" ball rules under 7.2.2.4.5.

6. Based on observation with the DOF present, over March 12 and March 13, 2015, the surveyor finds that three of three exit stairs in Building A and B and three of three exit stairs In Building C and D lack signs which clearly identify the exit stair with a unique identification label in accordance with 7.2.2.5.4. (example: although the Building A Northeast exit stair is identified verbally by the provider as "Stair A Northeast", there is no label inside the stair which includes this information and/or any information which allows that stair to be uniquely identified.

A. Based on direct observation, the surveyor finds an exit access was obstructed and an on-going project created deficiencies. The provider failed to implement interim life safety measures. Failure to implement and maintain adequate interim life safety measures could result in a fire, delayed response from life safety systems and staff, and could delay patient evacuation in an emergency.
.
Findings include:

1. At 1:15PM On March 12, 2015, with the DOF, VPOF and SO present, the surveyor observed a 2nd floor patient corridor which was obstructed by a temporary visqueen construction barrier creating a dead end corridor on both sides of the construction zone. Temporary exit signs and posted temporary evacuation plans were not provided. Adequate interim life safety measures were not found for this condition in accordance with 4.6.10 of NFPA 101 and NFPA 241.

Deficiencies included:

a. The visqueen used lacked an interior finish rating as a Class A, B, or C interior finish in accordance with 19.3.3.1.

b. Construction personnel were using a portable hand torch on the floor. A fire extinguisher and a dedicated fire watch were not found for this condition in accordance NFPA 241. The provider lacks a "hot work" or " burn permit" process as part of the facilities interim measures so the no cutting, welding, grinding or other hazardous construction activities can occur in the hospital without the provider's knowledge and documented permission, in accordance with NFPA 241.

B. Based on observation throughout the facility, the surveyor find doors which are identified as exits have delayed egress locking without the signs which are required. Other door deficiencies were also observed.

1. On March 12 and 13, 2015, with the DOF present, the surveyor observed, doors to exits and exit paths which are marked with exit signs have magnetic locking devices which do not have signage in accordance with 7.2.1.6.1.

Examples include but are not limited to


a. 2nd floor pair of designated smoke doors between Building A and Building B

b. 2nd floor door to Stair A Southwest

c. 3rd Floor door to Stair A Northeast

d. 3rd floor pair of doors Elevator Foyer AA

e. 3rd floor corridor door near Stair A Southwest.

f. 3rd floor door to the Building B center stair has magnetic locking device which lacks a sign. During testing by the surveyor at 3:10 PM with the DOF, VPOF and SO present, the surveyor found the doors took well in excess of 15 pounds of force to initiate the releasing action. [7.2.1.6.1 (c)]

2. At 3:15PM on March 13, 2015, with the DOF present, the surveyor observed one leaf of a pair of storage room doors in the kitchen had a single cylinder dead bolt lock which does not comply with 7.2.1.5.

3. At 3:00PM on March 13, 2015, with the DOF present, the surveyor observed that a pair of power operated sliding alum/glass doors in the emergency department's means of egress is equipped with a break and swing function. The doors lack a sign "In emergency push to open" in accordance with 7.2.1.9.

Based on observation, the surveyor finds the two-hour fire barriers are not constructed as two-hour barriers or have voids and penetrations which are not sealed for two-hour construction. Failure to maintain fire barriers could result in the spread of fire and smoke beyond the room of fire origin.

Findings include:

1. At 12:35PM on March 12, 2015, with the DOF, VPOF and SO in attendance, the surveyor observed the designated two hour barrier (masonry wall) between Building A and Building C at the 4th floor had a cable penetration which was not sealed for two-hour construction in accordance with 8.2.3.2.4.

2. At 11:45PM on March 13, 2015, with the DOF, VPOF, and SO in attendance, the surveyor observed the designated two-hour barrier (masonry wall) between Building A and Building C at the 1st floor had a cable penetration which was not sealed for two-hour construction in accordance with 8.2.3.2.4

Based on observation, the facility failed to maintain fire barriers. This could result in the spread of fire and smoke beyond the room of fire origin.

Findings include:

1. At 12:10 on March 13, 2015, with the DOF in attendance, the surveyor observed the designated two-hour barrier between Building C and Building D is not continuous from outside wall to outside wall. The fire barrier has no continuity in accordance with 7.2.4.3. The wall construction above a pair of cross corridor doors (a designated two-hour barrier) was observed to be one layer of drywall with voids. This condition is not considered two-hour construction as indicate on the plans dated 03/09/15. This locations is part of the continuous two hour barrier on all floors which separates Building C vertically from Building D.

Based on direct observation, the surveyor finds the emergency lighting with battery back up is not installed where required. This condition could result in complete and total darkness until lighting connected to the emergency generator comes on during a power failure.


Findings include

1. At 4:00PM on March 12, 2015, with two obstetrical nurses in attendance, the surveyor determined that the 4th floor C-section room lacks emergency lighting with battery back up in accordance with NFPA 99-1999, 3-3.2.1.2(a)5(e).

A. Base on direct observation, the surveyor find the ground floor, 1st floor and 2nd floor have required exit paths through a two-hour fire barrier into the corridors of Building C & D. These exit paths are identified on plans dated 03/09/15 as two-hour fire barriers and as two-hour occupancy separations. These exit paths are not identified on plans as a horizontal exit. The lack of correct designation could delay patient evacuation in an emergency.

Findings include:

a. March 12 and March 13, 2015, with the DOF, VPOF and SO in attendance, the surveyor observed these exit paths are not identified on plans as horizontal exits. This information is critical for the correct evaluation of Buildings A, B, C and D.

b. March 12 and March 13, 2015, with the DOF, VPOF and SO in attendance, the surveyor observed the above exit paths lack an illuminated exit sign on two of three floor levels (ground and 1st floor) in accordance with 7.10.1.

3. At 1:00PM on March 13, 2015, with the DOF, VPOF and SO in attendance, the surveyor observed the 5th floor roof extends across the Buildings A, B and C and has four or five mechanical penthouses and several elevator penthouses. None of the penthouses and no portion of the roof had any illuminated exit signs identifying the path to an exit in accordance with 7.10.1.

4. At 12:50 on March 13, 2015, with the DOF, VPOF and SO in attendance, the surveyor observed the 5th Floor Building C penthouse has an exit sign which was not illuminated and was mounted perpendicular to the wall such that it was not visible from most of the space.

B. Based on observation the surveyor finds illuminated exit signs are not provided correctly . This could delay patient evacuation in an emergency.

Findings include:

1. At 2:40PM on March 13, 2015, with the DOF in attendance, the surveyor observed the ground floor Emergency Department lacks an illuminated exit sign identifying the second path of egress from this area, in accordance with 19.2.10.1

Based on observation, the facility lacks proper illuminated exit signs. This could result in the delay of evacuation in a fire emergency.

Findings include:

1. At 11:45 AM on March 12, 2014, with the DOF, the VPOF and the SO in attendance, the surveyor observed a 4th floor vacant occupational health suite is located on the south half of Building C, lacks illuminated directional exit signs identify the exit path through a complicated arrangement of halls and rooms, in accordance with 39.2.10. This suite has access to an exit access corridor to the north and to the south east stair of Building C.

Based on a review of the life safety plans, dated 03/09/15, with the DOF at 9:00AM on March 12, 2015, and observation between the March 12 and 13, 2015 on multiple floors of the hospital, the surveyor finds the information provided on the above referenced plans is not accurate. This could affect the patients, visitors and staff evacuating the facility in the case of an emergency.

Findings include:

1. The plans indicate an exit stair from the south end of the roof of Building A. No exit stair was found from this part of the roof.

2. The exit stairs discharge into a corridor-like space which also has a two-hour enclosure. These spaces are not identified as exit passageways on the plans and the exit discharges do not comply unless they are exit passageways. The level of of exit discharge shown on the plan for two exit stairs is not in compliance.

3. A two-hour fire separation is identified on the plans between Building B and Building C. This barrier is also identified as an occupancy separation on the plans. The exit access corridor on the 2nd floor has an illuminated exit sign above the pair of 90-minute doors directing an exit path from Building B into Building C. The 1st floor and ground floor both have similar corridors where an exit path is required into Building C. Building C can be evaluated as a business occupancy and not health care if the two-hour fire barrier complies with the requirements of 19.1.2.4 as a horizontal exit. These two barriers are not identified as horizontal exits. The surveyor also note these two-hour barriers are required smoke barriers at this location on every floor

4. The lines used to identify smoke barriers on the plans date 03/09/15 are difficult to read. This makes it difficult to confirm the size of smoke compartments and travel distances to smoke doors.

5. Although two-hour fire barriers were observed on most floors between Building C and Building D, the surveyor observed that they do not continue through the kitchen on the ground floor between Building C and Building D; therefore, Building C and D have been evaluated as the same building. A two-hour fire separation is not identified on the plans dated 03/09/15 between Building D and an adjacent residential occupancy; however a two-hour fire separation and a 90-minute fire door was observed at this location with the DOF present. The plans are not accurate.

Based on observation and document review, the facility failed to maintain the fire alarm systems in accordance with the code. This could result in a failure of the fire alarm system in a fire emergency.

Findings include:

1. At 10:00 AM, on March 12, 2015, the surveyor along with the DOF, surveyed the Midtown Health Center. The surveyor requested documentation, quarterly, semi-annually and annual testing, maintenance and service documentation for the building's fire alarm system. The DOF indicated no documentation was available for this building, therefore, the surveyor finds the fire alarm system is not tested, serviced and maintained in accordance with NFPA 72 - 1999.

Based on observation and document, the facility failed to maintain the fire alarm systems in accordance with the code. This could result in a failure of the fire alarm system in a fire emergency.

Findings include:

1. At 10:30 AM, on March 12, 2015, the surveyor along with the DOF, surveyed the Midtown Plaza. The surveyor requested documentation, quarterly, semi-annually and annual testing, maintenance and service documentation for the building's fire alarm system. The DOF indicated no documentation was available for this building, therefore, the surveyor finds the fire alarm system is not tested, serviced and maintained in accordance with NFPA 72 - 1999.

A. Based on observation, the surveyor finds the sprinklered areas are compromised by missing ceiling tiles at lay-in ceilings or by obstructions. These conditions could delay notification of a fire in these spaces and delay evacuation in a fire emergency.

Findings include:

1. At 1:05 PM on March 12, 2015, with the DOF present, the surveyor finds that the 2nd floor rehabilitation storage room has a displaced ceiling tile which does not comply with NFPA 13.

2. At 11:30AM on March 12, 2015, with the DOF present, the surveyor finds the basement level is partially sprinklered. A large switchgear room is used for storage which conflicts with the requirements of NFPA 13 for unsprinklered spaces.

3. At 11:35AM on March 12, 2015, the surveyor observed a large maintenance shop/storage space which was evaluated as a hazardous area. The space is sprinklered; however, sprinkler heads are not installed below ductwork which is wider than 4'-0" in accordance with NFPA 13.

4. At 9:15AM on March 13, 2015, the surveyor observed a missing ceiling tile in the 3rd floor storage room opposite Room 307.

5. At 9:20AM on March 13, 2015, the surveyor observed a missing ceiling tile in the 2nd floor storage room opposite Building B Center Stair.

6. At 4:10PM on March 13, 2015, with the DOF present, the surveyor observed the 3rd floor OB mechanical room had only one sprinkler head which was obstructed. The entire room lacked sprinkler protection in accordance with NFPA 13. This room is identified on plans dated 03/09/15 with a two- hour fire rated enclosure. One of the walls was observed with a 12" x 12' void in it and the mechanical room is open to the adjacent ceiling cavity at this void. The room lacks a draft stop for the sprinkler protection and the adjacent ceiling cavity lacks sprinkler protection in accordance with NFPA 13.

7. At 2:35PM on March 13, 2015, with the DOF present, the surveyor observed that the main lobby entrance vestibule has three bays; only the center bay has a sprinkler head in accordance with NFPA 13.

8. At 3:40PM on March 13, 2015, the surveyor observed in the ground floor construction storage room, which is sprinklered, sprinkler heads are installed at lay-in ceiling height and most of the ceiling tiles are missing. The sprinkler heads are not installed in accordance with NFPA 13 and the corridor walls in this room has have unsealed penetrations. The walls are not smoke tight in accordance with 19.3.6.2.

9. At 3:00PM on March 13, 2015, with the DOF, VPOF and SO present, the surveyor observed a soiled utility room in the 4th floor ICU which has a garden hose hanging out of the ceiling with a leak collection barrier in the ceiling cavity. The ceiling cavity was not protected with a sprinkler system in the cavity in accordance with NFPA 13 requirements for protection of interstitial spaces with combustibles.

B. Based on observation between on March 12 and 13, 2015, with the DOF, VPOF and SO in attendance, the surveyor finds that the facility has a fire pump with static pressure on the system above 100PSI. Sprinkler heads with arm overs or end of branch support in excess of 24" were observed to lacks arm-over bracing at 12" in accordance with 6-2.3.3 of NFPA 13 - 1999.

Locations include but are not limited to:

1. 4th floor ICU

2. 4th floor pain clinic

3. 3rd Floor pediatrics waiting area


C. Based on observation between March 12, and 13, 2015, with the DOF present, the surveyor finds the sprinkler system is not installed in accordance with NFPA 13.

Findings include

1. At 2:00PM on March 13, 2015, with the DOF present, the surveyor conducted a sprinkler flow switch test, using the inspector's test valve in the janitor's closet near Room 225. The janitor's sink overflowed and was not able to handle the water flow from the inspector's test. This condition does not comply with NFPA 13.

The above condition also appears to be cited in the annual sprinkler system documentation for 2013 and 2014. There appeared to be other deficiencies cited in the documentation relative to tamper switches, gauges, valves and something identified as "Pressure: broken" PSI. The provider was not able to provide documentation or evidence identifying when and how these deficiencies were corrected.

Based on observation, the facility failed to maintain and install a proper sprinkler system. This could result in in uncontrolled fire spreading to all portion of the building.

Findings include;

1. At 10:10AM on March 12, 2015, the surveyor observed with the DOF in attendance, the transfer switch room lacked sprinkler protection. The room had a 90-minute fire rated door but the walls above the ceiling do not extend to the deck above as a compliant two-hour fire barriers in accordance with the exceptions for unsprinklered spaces under NFPA 13. The walls stop just above the ceiling.

Based on observation, personnel interview and document review the surveyor finds that the fire pump is not tested and maintained. Failure to test and maintain the fire pump could result in failure during a fire emergency.

Findings include

1. At 3:00PM on March 13, 2015, during document review with the DOF, the surveyor finds the documentation for annual fire pump testing for 2014 does not include the correct sequence of testing on emergency power from an emergency generator in accordance with NFPA 20.

2. At 3:00PM on March 13, 2015, during document review with the DOF, the surveyor finds the documentation of testing of four required monitoring points from the fire pump was not found on the annual fire pump documentation for 2014. Testing by the fire alarm contractor could not be confirmed; no documentation for testing of the fire alarm system was found for 2014.

3. At 3:00PM on March 13, 2015, during document review and interview with the DOF, the surveyor finds the documentation for testing and maintenance of the sprinkler system identifies five year testing as "NA". There is no indication as to when pressure gauges were last tested and when back flow devices were last internally inspected. No documentation observed onsite included five year testing in accordance with NFPA 25.

Findings include:

Based on observation and document review, the facility failed to maintain the sprinkler system in accordance with the code. This could result in a failure of the fire detection system in a fire emergency and the spread of fire, uncontrolled,to all portions of the building.

Findings include:

At 10:00 AM, on March 12, 2015, the surveyor along with the DOF, surveyed the Midtown Health Center . The surveyor observed that the building is sprinklered and requested documentation, quarterly, semi-annually and annual testing, maintenance and service documentation for the building's sprinkler system. The DOF indicated that no documentation was available for this building. The surveyor finds the sprinkler systems is not tested, serviced and maintained in accordance with NFPA 25 - 1999.

1. The lack of quarterly flow testing of sprinkler flow switches which includes the location of each switch and the time from water flow to activation of the fire alarm system.

2. The lacks of documentation for inspection, testing and maintenance of the sprinkler system in accordance with NFPA 25.

Based on document review for testing of fire damper and smoke dampers, the documentation does not comply with the six year testing of dampers. Fail to test and maintained fire and smoke dampers could result in failure and the spread of fire and smoke in a fire emergency.

Findings include:

1. At 4:00PM on March 13, 2015, during document review, the surveyor finds the 2009 documentation identified a significant number of deficient dampers. The surveyor finds that the documentation does not comply with NFPA 90A for six year testing of dampers. A unique identifying number or label is not provided for on each damper, the damper access, and the damper documentation in accordance with NFPA 90A.

2. At 4:00PM on March 13, 2015, during document review, the surveyor finds the location method for identifying specific dampers is vague (examples include multiple designations under "hall" and "chase FSD". Documentation for the combination fire/smoke dampers installed in fire barriers and corridors walls with a plenum return air system at the 1st floor was not found . The surveyor finds the documentation for testing is incomplete and does not demonstrate that all dampers were tested in accordance with NFPA 90A.

Based on observation, the surveyor finds the medical gas systems are not installed and maintain in accordance with code. This condition could result in the loss of medical gas systems during an emergency.

Findings include

1. At 1:00PM on March 13, 2015, the surveyor observed with the DOF present, the temporary construction fence around a temporary mobile emergency generator blocks access to the emergency oxygen fill located on the south side of the hospital. This condition does not comply with NFPA 99 and NFPA 50.

B. At 4:00PM on March 12, 2015, the surveyor observed with the DOF, VPOF and SO present, the 3rd floor C-section hallway had two medical gas shaft valves which were identified for Delivery Room #1 and Delivery Room #2. The DOF indicate the rooms no longer exist. The surveyor finds the labeling of these valves does not comply with NFPA 99 and the valves were not "tagged out" or properly terminated in accordance with NFPA 99.

C. At 2:00PM on March 13, 2015, the surveyor observed with the DOF, VPOF and SO present, the ground floor cardiopulmonary suite has a storage room with 28 oxygen tanks (e tanks). These tanks were not stored in a room designed for oxygen storage and/or they were stored in a room without a clear separation from all combustibles of 5'-0" in accordance with NFPA 99.

Based on observation, the surveyor finds the emergency generators are not installed and maintained in accordance with code. These conditions could result and loss of emergency power during failure of normal power to the facility.

Findings include:

1. At 11:00PM, on March 12, 2015, with the DOF present, the surveyor observed the facility has two emergency generators in the basement level in a fire rated enclosed generator room. One is a new generator under construction which replaced an existing generator in the same location. A 3rd generator is installed on the roof and a 4th emergency generator is a temporary mobile unit installed in the South Parking Lot.

The remote stop for the two generators in the basement lack unique identification to clearly indicate which generator is connected. The temporary mobile generator does not have a remote stop and the emergency stop button installed on the mobile generator is not accessible without delay due to the chain link fence in front of it. These conditions do not comply with NFPA 99 and NFPA 110.

2. At 11:05PM on March 12, 2015, with the DOF, VPOF and SO in present, the surveyor observed the basement level generator room has multiple air intake louvers with fire dampers. One louver was partially blocked off with rigid insulation. The use of this combustible material in front of the fire damper does not comply with NFPA 90 A and the damper manufacturer's installation requirements.

3. At 11:10AM on March 12, 2015, with the DOF present, the surveyor observed construction activity in the generator room with a new generator being installed. Access was restricted by contractors and construction materials including two fifty gallon barrels of hydraulic fluid which are not permitted to be stored in this room under NFPA 99 and NFPA 110. No fire watch was found.

Based on observations and staff interviews during the survey walk-through, March 12-13, 2015, and based on document review, and staff interview, the surveyors find the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

Findings include:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on a review of the documentation the surveyor finds the emergency generators are not documented and tested properly. Failure to test and maintain emergency power systems could result in failure during loss of normal power.

Findings include

1. At 4:00PM on March 13, 2015, during document review with the DOF present, the surveyor finds the documentation for three of three emergency generators identifies only that each is a 250 KVA generator. The documentation does not clearly identify which generator was tested by model numbers, serial number or other unique identification. The documentation also does not clearly identify which transfer switches were used for each test. This documentation does not comply with NFPA 70, NFPA 99 and NFPA 110.

3. At 4:00PM on March 13, 2015, during document review with the DOF present, the surveyor observed a gap in the documentation which indicates no monthly testing occurred between 6/13/14 and 9/26/14. This period for testing does not comply with NFPA 70, NFPA 99 and NFPA 110.

2. At 4:00PM on March 13, 2015, during document review with the DOF present, the surveyor finds the documentation for periodic testing of emergency power transfer switches is incomplete. The documentation for each transfer switch does not clearly identify the date the test was conducted and which generator was used during the test. This documentation does not comply with NFPA 70, NFPA 99 and NFPA 110.

3. At 10:00AM on March 12, 2015 , the surveyor observed a temporary mobile emergency generator in the South Parking Lot and at 4:00PM on March 13, 2015, during document review at with the DOF present, the surveyor finds the provider has no documentation which identifies a weekly visual inspection of this generator in accordance with NFPA 99 and NFPA 110.

Based on observation, the surveyor observed the electrical systems and materials are not installed and maintained. This condition could delay any response during and electrical emergency.

Findings include:

1. At 1:45PM on March 12, 2015, with the DOF present, the surveyor finds in the basement level generator room, access to switchgear was blocked by contractor equipment carts. At least 3'-0" of clear space is not maintained in accordance with NFPA 70.

2. At 2:00PM on March 12, 2015 with the DOF present, the surveyor finds the basement level switchgear, near the assistant manager's office, access was blocked by combustible storage. At least 3'-0" of clear space is not maintained in accordance with NFPA 70.

3. At 2:00PM on March 12, 2015, with the DOF present, the surveyor observed the switchgear for the CT AHU lacked an identifying label on the outside of the panel in accordance with NFPA 70 and access was blocked by storage. At least 3'-0" of clear space is not maintained in accordance with NFPA 70.

4. At 11:35AM on March 12, 2015, with the DOF present, the surveyor observed a large maintenance shop/storage space with electrical panels and switchgear at the far end of the room. Access was blocked by storage in front of the panels. At least 3'-0" of clear space is not maintained in accordance with NFPA 70.

5. At 11:40AM on March 13, 2015, with the DOF present, the surveyor observed a 3rd floor surgical staff lounge with a large table and chairs in front of the electrical panels. Access was obstructed for six of six electrical panels. At least 3'-0" of clear space is not maintained in accordance with NFPA 70.

6. At 11:15AM on March 13, 2015, with the DOF, VPOF, and the SO present, the surveyor observed a blue electrical extension cord hanging out of the ceiling of the corridor wall north of the pharmacy. This extension cord was not installed in accordance with NFPA 70 for a permanent electrical device.