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A) Based on random observation, during the survey walk-through of the facility on 03/24/2011 the surveyor finds that exit access corridors are not separated from use areas in accordance with 19.3.6.1.

Findings include:

1. 9:30 am: During the walk-through, the surveyor observed that the Control Machine Area for the CT Room - (First Floor - Imagery Department) has a missing door and is not being separated from the exit access corridor to comply with 19.3.6.1.

A) Based on record review and staff interview in the Administrator's Office, it was determined that the Imagery Unit was not a designated suite as shown from the facility's Life Safety drawing and as indicated on the plan of correction. During a tour of this Area on 03/24/2011 the surveyor finds multiple exit access corridor doors that are defficient due to a thumbturn deadbolt hardware that requires more than one releasing mechanism operation to exit the room and does not comply with 7.2.15.4. Deficient practice could affect staff, and visitors.

Findings include:

1. 9:30am- During the walk through the surveyor oberved thumturn deadbolt hardware
in the following Rooms:

a. Library /Break Room.

b. Store Room/Printer Room.

2. 9:35am- During the walk through, the surveyor observed a non positive latching exit
access corridor door to the radiologists room that does not comply with 19.3.6.3.2.

A. Location observed Machine Room #2 with access from the East Stair - Due to the lack of damper installations (fire rated separations) at the duct floor penetrations, the machine room is considered an extension of the vertical fire rated shaft. However, the machine room does not comply with NFPA 90A 3-1.3 or NFPA 101 39.3.1 and 8.2.5 due to the following:

1. The machine room floor does not maintain the minimum required fire rated separation of the vertical shaft due to unprotected structural steel members such as the metal deck, beams and joists to comply with 8.2.5.4.

2. The machine room is being used for the storage of combustibles which does not comply with 39.3.2.

Update 9/16/2010: See K-tag 029 update, unable to clear this tag yet. We will continue to monitor spaces during follow up surveys.
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A. Based on random observations during the survey walk through, areas open to corridors are observed which pose a degree of hazard greater than that normal to the general occupancy which does not comply with 19.3.2.1.

1. a. Corrected 09/16/2010.
b. Corrected 09/16/2010.
2. Corrected 09/16/2010.

Update 09/16/2010: Corrected 03/24/2011.


3. Location observed: Kelly's Medical Supply located in the Main Hospital exit access corridor adjacent to the Main Lobby and the Gift Shop. Surveyor observed a nonseparated hazardous area deemed as storage by the Authority Having Jurisdiction. Further this space is leased and does not maintain the same hours as the Hospital. This area contains numerous combustible materials ie. foam bed supplies, numerous combustibles wrapped in plastic and cardboard boxes lined along three walls of shelves. The adjacent areas are not separated or adequately protected due to the following:

a. This area appears to be an occupancy change in which the corridor sprinkler system area of protection was not verified to comply with NFPA 13 1999, 5-6.3 and NFPA 25 1998, 2-2.1.1.

b. The ceiling is open to and relys on the main corridor's pitched clearstory ceiling which contains one sprinkler head at the peak.

c. The area lacks separation from the corridor due to the use of an open metal sliding grille which does not comply with 19.3.2.1 for the requirements of a 1-hour fire rated separation or smoke tight walls with a self closing door.

Update 09/16/2010: The Kelly Medical Supply located in the exit access corridor adjacent to the Main Lobby and the Gift Shop has been viewed during this survey. We note that this space will be continued to be monitored for future monitoring surveys. We are unable to clear this tag until construction for the new area is completed.

B. Surveyor observed a place of assembly which is open to an area which poses a degree of hazard greater than that normal to the general occupancy. This does not comply with 13.3.2.1.3 (2) for areas of assembly.

1. Location observed: First Floor 1953 building Kitchen (greater than 500 square feet - deemed hazardous due to the amount of combustibles being stored) which is open to the Cafeteria (area of assembly). Hospital staff were unable to indicate the exact location of the 1-hour fire resistant barrier(refer to C. 1. this K-Tag). The Cafeteria is provided with sprinkler protection, however, the Kitchen did not appear to be sprinkler protected.


C. Surveyor observed a non sprinkler protected kitchen (greater than 500 square feet) which is open to the means of egress due to a door which was held open by a door wedge which does not comply with 8.4.1.3 for self closing, 3/4 hour fire rated door in a barrier (Facility provided Life Safety Drawings indicate this wall as a 1-hour barrier).

1. Location observed: First Floor 1953 building Corridor dooor for Kitchen. Based on random observations during the survey walk through, areas which pose a degree of hazard greater than that normal to the business occupancy does not comply with 39.3.2.1 and 8.4.1.1.


D. 1. a. Corrected 09/16/2010.
b. Corrected 09/16/2010.
c. Corrected 09/16/2010.

E. 1. Corrected 09/16/2010.
2. Corrected 09/16/2010.
F. Corrected 09/16/2010.

G. Location observed Machine Room # 2 with access from the East stair - the machine room is considered an extension of the adjacent storage room which does not comply with 39.3.2 and 8.4.1.1 due to the following:

1. The machine room is not separated from an adjacent storage room due to the unprotected through wall duct penetration.

Update 9/15/2010: The Machine Room which is considered an extension of the adjacent storage room and also part of the vertical shaft that was being used as a storage. The surveyor has viewed spaces being emptied during this survey. We will continue to monitor the spaces until this vertical shaft has been removed during construction of the new facility.

A. The surveyor finds that Hospital Departments on the 1st Floor appear to be a very large suites with multiple rooms. The size and boundaries of the suite were not identified by the provider. The surveyor finds that some patient treatment rooms (example: Nuclear Med and Ultrasound) must pass through two or more intervening rooms to get to an exit access corridor and that travel distances exceed the 50' limit of 19.2.5.8. The surveyor notes that the travel distances for some of the rooms may exceed 100'.

Example locations include:

1. Corrected 09/16/2010.
2. Corrected 09/16/2010.

3. Corrected 03/24/2011.

4. 2nd Floor Surgery area including the semi-restricted and restricted corridors which the O.R. rooms must pass in order to arrive at an exit access corridor.

Update 9/16/2010: 2nd Floor Surgery area- The surveyor is unable to clarify the travel distance during the survey walk-through. Travel distances to designated access corridors from this suite are not identified on the facility's Life Safety Drawings.

Update 03/24/2011: 9:25am-During staff interview and review of the Life Safety drawings the surveyor was unable to clear this tag, based from these plans that are not complete to verify travel distances, designated boundary of suites and exits which not clearly defined.

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A. During a review of the facility's fire protection plan documents, compared to the survey walk through it was determined that the facility has not accurately maintained a comprehensive set of building floor plans, which show critical elements of its egress and fire/smoke compartmentalization systems, for compliance with 19.7.1.1. Critical elements of these systems which are not shown or not shown accurately on the facility's Life Safety Master Plans include:

1. Locations and sizes of smoke compartments.

2. Designated suites including square footage and the perameter of the suite.

3. Sprinklered portions of the building and designated separations between sprinklered and non sprinklered areas.

4. Exit discharge enclosures designated exit passageways and their fire resistance.

Update 9/16/2010: The surveyor was unable to clear this tag during this survey because the updated Life Safety Drawings do not identify travel distances from the suite, designated exits and exit passageways do not appear to comply with Sections 7.1 and 7.2.6.1.

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A. Based on direct observation the surveyor finds in the 53 Building not all facility identified duct penetrations have fire/smoke dampers installed as identified by the facility inventory. Locations include but not limited to:

1. The fire rated barrier between OT Satellite Treatment and Administration Offices. (NFPA 90A, 1999, 3-3)


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A. Corrected 9/16/2010.
B. Separation of medical gas zone control valves from supplied outlets and inlets in the emergency department. (NFPA 99, 1999, 4-3.1.2.3 (d)



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A. A701 CFR 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured.
In particular spaces containing storage such as the closets for the gift shop located along the east/west exit corridor of the 1994 Building. First indication was that the gift shop manager had the only keys and that individual was not available to provide access. Engineering eventually provided a key after considerable time had passed. Should an incident within the stored areas occur, the time delay in responding jeopardizes the safety of patients, staff and visitors. The storage closets fire protection is compromised by stored items on shelves which are closer than 18 inches the ceiling (refer to K-Tag 056 item E).



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B. 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.





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A) Based on random observation, during the survey walk-through of the facility on 03/24/2011 the surveyor finds that exit access corridors are not separated from use areas in accordance with 19.3.6.1.

Findings include:

1. 9:30 am: During the walk-through, the surveyor observed that the Control Machine Area for the CT Room - (First Floor - Imagery Department) has a missing door and is not being separated from the exit access corridor to comply with 19.3.6.1.

A) Based on record review and staff interview in the Administrator's Office, it was determined that the Imagery Unit was not a designated suite as shown from the facility's Life Safety drawing and as indicated on the plan of correction. During a tour of this Area on 03/24/2011 the surveyor finds multiple exit access corridor doors that are defficient due to a thumbturn deadbolt hardware that requires more than one releasing mechanism operation to exit the room and does not comply with 7.2.15.4. Deficient practice could affect staff, and visitors.

Findings include:

1. 9:30am- During the walk through the surveyor oberved thumturn deadbolt hardware
in the following Rooms:

a. Library /Break Room.

b. Store Room/Printer Room.

2. 9:35am- During the walk through, the surveyor observed a non positive latching exit
access corridor door to the radiologists room that does not comply with 19.3.6.3.2.