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Based on observation during the survey walk-through, staff interview and review of facility provided information, the construction type of the building does not comply with requirements. This deficiency could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:

A. At 11:30am on 5/12/15 it was observed while in the company of administrative and maintenance staff at the West Building South Wing 4th floor old on-call room area in storage room W482 that structural steel roof framing was not protected to provide the minimum 1-hour fire rating for the identified Type II (222) construction type in accordance with NFPA 101-2000, 19.1.6.2 and NFPA 220. The extent of the unprotected steel was not confirmed at the old on-call rooms due to lack of available keys to access the area or above the ceilings.

B. Corrected 4/14/16.

C. Corrected 4/14/16

D. At 9:20am on 5/12/15 it was observed while in the company of administrative and maintenance staff at the West Building North Wing 6th floor corridor near Endo Lab 648 that ceiling light fixtures appeared to be "tented" to form a rated floor/ceiling assembly. Not all fixtures were observed to have complete five-sided "tenting" in accordance with the requirements of a UL tested assembly to provide the required protection in accordance with NFPA 101-2000, 19.1.6.2 and NFPA 220. Similar conditions were noted at the 7th floor corridor above at the roof/ceiling assembly which appeared to be utilized.

E. At 10:35am on 5/12/15 it was observed while in the company of administrative and maintenance staff at the West Building South Wing 4th floor exhaust fan "room" (under the roof slope) that veneer plywood was installed and exposed on one side of metal stud framing at the bottom half of the wall. The use of combustible wood construction for interior walls of this building identified as Type II (222) construction type does not comply with NFPA 101-2000, 19.1.6.3.

F. Corrected 4/14/16.


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G. At 8:32 AM on 5/13/2015, accompanied by the facility's Quality Specialist and a Maintenance Staff Member, in the construction area that will be the remodeled Cath Lab on the first floor of the East building, wood formwork construction was observed to be present in the second floor construction, which does not comply with 19.1.6.2.

H. Corrected 4/14/16

Based on direct observation during the survey walk through, accompanied by the facility Director of Plant Operations, Safety Officer, and Building Engineer, the surveyor finds that not all exit access corridors are separated from use areas. These deficiencies could affect any patients, staff, or visitors in the immediate area by permitting smoke to enter the egress corridor.

Findings include:

A. At 10:05 AM on May 12, 2015, the waiting area, outside the PT suite on the second floor, south end of the North Building, is not sprinkler protected and open to the adjacent corridor, was observed to not be constantly attended and does not comply with 19.3.6.1 Exception No. 2.

Based on observation during the survey walk-through not all doors in exit access corridors are in compliance. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. Corrected 4/14/16.

B. At 2:25pm on 5/13/15 it was observed while in the company of administrative and maintenance staff at the West Building North/Center Wing 1st floor at the "Fast Track" suite corridor door near Stair #4/Elevator #6 that the pair of doors was equipped with a power opener and magnetic locking devices with delayed egress without positive latching to comply with NFPA 101-2000, 19.3.6.3.2. The magnetic lock functions as the latching device except during delayed egress function or fire alarm activation when the magnets release. The power opener does not release the magnets when turned off. The power opener was not verified to cease operation during fire alarm activation in accordance with NFPA 101-2000, 7.2.1.9.2.


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C. Corrected 4/14/16

D. At 10:57 AM on 5/13/2015, accompanied by the facility's Quality Specialist and a Maintenance Staff Member, the pair of corridor doors that lead to the first floor Emergency Suite from the corridor adjacent to Elevators 5 and 6 in the East Building were observed to not be equipped with latching hardware, which does not comply with 19.3.6.3.2.

E. Corrected 4/14/16

Based on observation during the survey walk-through, not all doors in exit access corridors are in compliance. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. At 9:26 AM on 5/14/2015, accompanied by the facility's Plant Operations Assistant Manager and Quality Specialist, on the second floor of the Wyman Building, the corridor door that serves Dining Room WG230 was observed to have unsealed penetrations, which does not comply with 19.3.6.3.1.

Based on observation during the survey walk-through, vertical openings between floors are not protected in compliance with NFPA 101-2000, 19.3.1.1, 8.2.5 and NFPA 90A-1999. These deficiencies could result in the effects of fire and smoke on one floor level transferring to another floor level and smoke compartment compromising the safety of patients, staff and visitors during a fire/smoke event.

Findings include:

A. At 10:30am on 5/12/15 at the West Building Center Wing 4th floor storage/mechanical room while in the company of administrative and maintenance staff it was observed that ducts through the floor had fire dampers which were not located in the plane of the floor and could not be confirmed to be installed within compliant sleeves to permit this installation in accordance with NFPA 90A-1999, 3-4.6.

B. Corrected 4/14/16

C. At 9:30am on 5/13/15 at the West Building North Wing 2nd floor fan room/shaft adjacent Stair 10 while in the company of administrative and maintenance staff it was observed that exhaust ducts penetrating the corridor shaft wall could not be confirmed to have fire dampers to comply with NFPA 90A-1999, 3-3.4.4 because no access doors were provided in accordance with NFPA 90A-1999, 2-3.4.

Based on observation during the survey walk-through while in the company of Administrative and Maintenance staff, not all designated or required smoke barrier doors are constructed or maintained as minimum 20 minute fire rated assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Finding include:

A. At 1:30pm on 5/12/15 while in the company of administrative and maintenance staff at the East Building 4th floor it was observed during fire alarm activation that the smoke barrier door near room 417 did not return to a closed position when opened after closing upon fire alarm activation to comply with 19.3.7.6.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's exit access corridors.

Findings include:

A. At 1:10pm on 5/13/15 while in the company of Administrative and Maintenance staff it was observed at the West Building South Wing 1st floor Kitchen storage area containing room W153 that the area was not provided with complete sprinkler protection or was not otherwise enclosed with 1-hour construction to comply with 19.3.2.1 and 8.4.1. The kitchen storage area is viewed as a single hazardous area comprised of multiple adjacent rooms. The door at the corridor south of the area was not minimum 3/4-hour fire resistance labeled.


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B. Corrected 4/14/16
C. Corrected 4/14/16

Based on direct observation the surveyor finds that hazardous areas are not properly enclosed. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's exit access corridors.


Findings include:

A. At 11:20 AM on 05/12/15, Second Floor (non sprinklered compartment), the surveyor finds the former patient room near Staff Note Working Area, which has been converted into a Storage Room, lacks a self-closing door to comply with 19.3.2.1.

B. At 8:30 AM on 05/13/15, Lower Level, the door to the File Room for the Audiologist is not self-closing to comply with 19.3.2.1.

Based on observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2.1.(a). These deficiencies could affect any patients in the facility that must utilize the exit, as well as any staff and visitors present by compromising the required protection of the exit enclosure and preventing those occupants from reaching an exit from the building.

Findings include:

A. Corrected 4/14/16
B. Corrected 4/14/16
C. Corrected 4/14/16

D. At 1:45pm on 5/13/15 at the West Building Central Wing 1st floor Stair #7 while in the company of Administrative and Maintenance staff it was observed that the in-swinging door from the east was not provided with a fire resistance rating label to comply with NFPA 101-2000, 8.2.3.2.3.1.

E. Corrected 4/14/16

F. At 1:50pm on 5/13/15 at the West Building Central Wing 1st floor Stair #7 exit passageway stair discharge, it was observed while in the company of Administrative and Maintenance staff that the door from this exit passageway to the Linen Transport room was not fire resistance labeled.

G. Corrected 4/14/16

H. During the course of the survey and review of available Life Safety Reference Plans it is observed that Exit Stair Discharge does not comply with NFPA 101-2000, 7.7 based upon the following:

1. The West Building 7th floor level is served by Stairs #4, #8, #9, #10. Only Stair #10 discharges to the exterior. The requirements of 7.7.2 are not met for this floor level.

2. The 5th and 6th floor levels are served by Stairs #1, #2, #4, #8, #9, #10. Only Stair #1 & #10 discharge directly to or through an exit passageway to the exterior. The requirements of 7.7.2 are not met for these floor levels.

3. The 4th floor level (except South Wing) is served by Stairs #1, #2, #4, #8, #9, #10. Stair #7 serves only the Storage/mechanical room on the 4th floor. Only Stairs #1, #7 & #10 discharge directly to or through an exit passageway to the exterior. The requirements of 7.7.2 are not met for this floor levels.

4. The 4th floor level South Wing is served by Stairs #6 & #13. Both discharge to the exterior. The requirements of 7.7.2 are met for the South Wing 4th floor level.

5. The 3rd floor level (except East Building Mechanical room Upper & Mid-level areas) is served by Stairs #4, #6, #7, #8, #9, #10 & #13. Only Stair #6, #7 & #10 discharge directly to or through an exit passageway to the exterior. The requirements of 7.7.2 are not met for this floor levels.

6. The 2nd floor level (except East Building Mechanical room including the Upper & Mid-level areas) is served by Stairs #4, #5, #6, #7, #8, #9, #10 & #13. Stairs #5, #6, #7, #10 & #13 discharge directly to or through an exit passageway to the exterior. The requirements of 7.7.2 are met for the 2nd floor level.

7. The Lower level is served by Stairs #1, #2, #3, #4, #5, #6, #8, #9, #10, #13 & an exterior areaway stair. Stairs #1, #5, #6, #10, #13 & the exterior areaway stair discharge directly to or through an exit passageway to the exterior. The requirements of 7.7.2 are met for the 2nd floor level.

The above tabulation indicates that Exit Stairs serving the 7th, 6th, 5th, & 4th floors (modified 5/27/16-4th floor originally noted to be the 3rd floor) do not comply with NFPA 101-2000, 7.7.2 which only permits up to 50% of the number of Exits to discharge to the interior provided the discharge level is fully sprinklered or the discharge level area is separated from non-sprinklered areas by 2-hour construction.

I. At 2:30pm on 5/12/15 during fire alarm testing it was observed at the East Building 3rd floor Upper & Mid-level Mechanical area that access to exits did not comply with NFPA 101-2000, 40.2.5 as an Industrial occupancy area. The common path of travel for the 3rd floor area exceeds that permitted by 40.2.5.3.


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J. Corrected 4/14/16

Based on direct observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies. This deficiency could affect any patients, staff, or visitors utilizing the exit stair by permitting smoke or fire to enter the exit stair enclosure.

Findings include:

A. At 9:40: AM on May 12, 2015, First Floor, while accompanied by the provider's Plant Operations and the Building Engineer. The surveyor observed duct pentrations through the 2-hour fire rated exit stair discharge enclosure for Exit Stair #11 are not provided with fire dampers and access panels to comply with 19.3.1.1, 7.2.6 and 7.1.3.2.1 (e) Exception No. 1.

Based on direct observation during the survey walk-through, accompanied by facility staff, not all stairs used as exits are constructed in accordance with code. These deficiencies could affect any patients, staff, or visitors in the building by creating a fall hazard during evacuation of the building under emergency conditions.

Findings include:

A. Corrected 4/14/16
B. Corrected 4/14/16
C. Corrected 4/14/16
D. Corrected 4/14/16

E. At 10:45am on 5/12/15 while in the company of Administrative and Maintenance staff at the West Building Center Wing 4th floor Storage/mechanical room, it was observed that the marked exit stair to the 3rd floor landing of Stair #7 had the door at the 4th floor level that does not swing in the direction of egress to comply with NFPA 101-2000, 7.2.1.4.3 and the door from this stair at the 3rd floor landing of Stair #7 was observed to have a single riser at the threshold of the door which does not comply with NFPA 101-2000, 7.2.1.3.

UPDATE 5/27/16: A waiver for the step at the third floor landing level was granted by CMS November 19, 2015. This portion of the above deficiency requires no corrective action.


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F. Corrected 4/14/16

Based on observation during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At various times during the survey walk through while in the company of Administrative and Maintenance staff, in multiple locations in the West Building, egress doors were observed that are equipped with magnetic locking devices. The West Building is not protected throughout by a sprinkler system or fire detection system, so the presence of delayed egress locks or magnetic locking devices are not in compliance with the general requirements of 7.2.1.6.1.

Examples include:

1. At 10:40am on 5/12/15-3rd floor OB Unit east doors. These doors do not comply with the general requirements of 7.2.1.6.1 for delayed egress locks including the signage required by 7.2.1.6.1(d).

2. Corrected 4/14/16

3. At 1:25pm on 5/13/15-1st floor Food & Nutrition Storage room. This door's magnetic lock is released on the egress side by only a push-button on the wall. The installation does not comply with 7.2.1.6.2 as an access controlled egress door locking system.

4. At 1:30pm on 5/13/15-1st floor exit passageway from Stair #7 exterior doors. These doors do not comply with the general requirements of 7.2.1.6.1 for delayed egress locks including the signage required by 7.2.1.6.1(d) or 7.2.1.6.2 as access controlled egress doors.

5. At 2:25pm on 5/13/15-1st floor "Fast Track" doors near Stair #4. These doors do not comply with the general requirements of 7.2.1.6.1 for delayed egress locks.

6. At 2:30pm on 5/13/15-1st floor "Fast Track" doors to the north waiting area. These doors do not comply with the general requirements of 7.2.1.6.1 for delayed egress locks or 7.2.1.6.2 as access controlled egress doors.

B. At 3:20pm on 5/13/15 at the East Building Cardiac Suite it was observed while in the company of Administrative and Maintenance staff that the east corridor pair of doors were equipped with panic device hardware and an astragal to close the 3/8"+/- gap between the doors. The astragal prevents each door from operating independently, thereby preventing the use of one door equipped with panic hardware without operating the other door. This arrangement does not comply with 7.2.1.5.5.

C. At 2:45pm on 5/13/15 at the East Building 1st floor corridor serving as the discharge path for Stair #4, it was observed while in the company of Administrative and Maintenance staff that the exit path from the corridor is directed through the designated Emergency Dept. suite waiting area which does not comply with 7.5.1.7. This corridor otherwise exits into the enclosed Ambulance Garage deemed to be a hazardous area due to vehicle storage which is also not permitted by 7.5.1.7. Stair #4 discharge does not comply with 7.7 (See K033).


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D. At various times during the survey walk through, accompanied by the facility's Plant Operations Assistant Manager and Quality Specialist, in multiple locations in the East Building, egress doors were observed that are equipped with delayed egress locking. The East Building is not protected throughout by a sprinkler system or fire detection system, so the presence of delayed egress locks does not comply with the requirements of 7.2.1.6.1. Examples include:

1. At 10:05 AM on 5/12/2015 - Stair 1, fourth floor Peds Unit.
2. At 10:10 AM on 5/12/2015 - Smoke barrier door, fourth floor near Room E419.
3. At 11:10 AM on 5/12/2015 - ICU Suite, exit door into OR Corridor, second floor.
4. At 8:55 AM on 5/13/2015 - MRI Suite, first floor.
5. At 10:47 AM on 5/13/2015 - Emergency Suite, first floor.

E. At various times during the survey walk through, accompanied by the facility's Plant Operations Assistant Manager and Quality Specialist, in multiple locations in the East Building, doors were observed that are identified as exits but equipped with magnetic locks that required a card to open, which does not comply with 19.2.2.2.4. Examples include:

1. At 10:22 AM on 5/12/2015 - Doors into the OR Corridor and Physicians' Lounge, second floor.

2. At 8:52 AM on 5/13/2015 - Exterior exit discharge doors at the corridor between the Administrative Suite and the MRI Suite, first floor.

F. Corrected 4/14/16

G. At 9:25 AM on 5/12/2015, accompanied by the facility's Quality Specialist and a Maintenance Staff Member, on the first floor of the East Building, a door near the Blood Draw Station in the Lab Suite is marked with an exit sign but leads to the Radiology Suite, which does not comply with 19.2.5.1.

H. At 10:27 AM on 5/12/2015, accompanied by the facility's Plant Operations Assistant Manager and Quality Specialist, on the second floor of the East Building near the OR, doors into the Men's and Women's Locker Rooms from the east corridor located behind the locker rooms were observed to be marked with exit signs. Egress from a corridor into a room does not comply with 19.2.5.9.

Based on observation during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Corrected 4/14/16

B. At 9:45am on 5/14/15 while in the company of Administrative and Maintenance staff at the Wyman-Gordon Building 1st floor lobby area near the stair which provides access to the tunnel to the main hospital, it was observed that the door to the west was marked as an exit and was locked to prevent egress by any public occupants that may be in this lobby area. Doors beyond this door were also locked as part of the locked unit.

C. At 9:30am on 5/14/15 while in the company of Administrative and Maintenance staff at the Wyman-Gordon Building 1st floor Home Care portion of the building which serves only outpatients, it was observed that exits are not provided in accordance with 39.2.4 relative to the number of exits and 39.2.10 relative to the marking of exits.

1. The Surveyor notes that the main corridor is provided with exit signage only at the east end of the corridor at the main entry doors. The travel distance from the exterior exit door to the door at the 2-hour building/occupancy separation exceeds the 100' common path of travel permitted by 39.2.4.2 Exceptions. The door at the 2-hour building/occupancy separation was not provided with exit signage to permit access to an unimpeded exit within the healthcare occupancy of the Wyman-Gordon building.

2. The Surveyor notes that the corridor serving the classroom areas and the office area is provided with exit signage only at the north end of the corridor and none of the doors through the office areas which have exterior exit doors are marked as exits and are locked. The travel distance from the south classroom to the main corridor (where access to two exits could be available upon correction of item C1 above) exceeds the 100' common path of travel permitted by 39.2.4.2 Exceptions. Compliant Exits from the classroom area corridor are not provided.

Based on observation and staff interview during the survey walk-through, while accompanied by Administrative and Maintenance staff, not all exit discharge locations are provided with illumination. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. At 1:30pm on 5/13/15 at the West Building Center Wing 1st floor it was observed that the lighting provided at the Stair #7 exit passageway discharge exterior stair and the access to the public way was a single HID type lamp not of the instant-on type (incandescent, fluorescent, quartz or LED) to provide lighting of the means of egress in accordance with 7.8.1.2, 7.8.1.3, and 7.8.1.4. This lighting was not verified to be on the life safety branch of the emergency power system to comply with 7.9.

B. At 2:05pm on 5/13/15 at the West Building North Wing 1st floor it was observed that the lighting provided at the Stair #10 exit discharge was not a minimum of two lamps so as not to leave the area in darkness upon failure of a single lighting unit to comply with NFPA 101-2000, 7.8.1.4. This lighting was not verified to be on the life safety branch of the emergency power system to comply with 7.9.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. At 9:05am on 5/12/15 at the West Building North Wing 7th floor while in the company of Administrative and Maintenance staff it was observed that the smoke barrier cross corridor doors lacked exit signs on both sides to identify the egress path to the 2nd exit from the floor to comply with 19.2.10.1 and 7.10.1.2.

B. At 10:15am on 5/13/15 at the West Building South Wing 1st floor while in the company of Administrative and Maintenance staff it was observed that the corridor serving the Auxiliary Offices lacked a fully visible exit sign at the east end of the corridor when viewed from near the midpoint of the length of the corridor to comply with 19.2.10.1 and 7.10.1.2.

Based on observation during the survey walk through, the surveyors find that the fire alarm installation did not meet all of the requirements of NFPA 72-1999. This could affect all occupants of the areas served if the fire alarm system does not operate properly during a fire emergency.

Findings include:

A. At 1:30pm on 5/12/15 at the West Building North Wing 3rd floor while in the company of Administrative and Maintenance staff it was observed that the fire alarm audio/visual device located near Stair #10 was not functioning.

B. At 1:30pm on 5/12/15 at the West Building North Wing 3rd floor while in the company of Administrative and Maintenance staff it was observed that the manual pull station was not located within 5' of the exit doorway to comply with NFPA 72-1999, 2-8.2.2.


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Based on observations made during the survey walk through while accompanied by the Director of Security, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA-72. This could affect all occupants of the building if the fire alarm system did not operate properly during a fire emergency.

Findings include:

C. The surveyor observed on the morning of 5/12/2015 while accompanied by the Director of Security that the elevator machine rooms throughout the east and west portion of the main building did not have a heat detector within 2' of each sprinkler head tied to a shunt trip as required by NFPA-72, Section 3-9.4, and ASME A17.1, Section 102.2(c)(3).

D. The surveyor observed at approximately 1:15 PM on 5/12/15 that several fire alarm strobes were not working in the east/west building.

Examples include but are not necessarily limited to:
1. At the corridor adjacent the Admitting offices.
2. At corridor east of Cardiology suite.
3. At the corridor east of Kitchen Storage.


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Based on direct observation during the survey walk-through, accompanied by facility staff, the facility failed to provide a fire alarm system with approved components, devices or equipment installed in accordance with NFPA 72. This deficiency would affect all occupants if there was a delay in the fire alarm system's response time during a fire.

Findings include:

E. Corrected 4/14/16
F. Corrected 4/14/16
G. Corrected 4/14/16

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with code. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

A. At 8:45 AM on May 13, 2015, while accompanied by the Director of Plant Operations and Building Engineer, the surveyor observed a smoke detector in the electrical room, lower level, which is located within 3'-0" of supply air diffuser as prohibited by NFPA 72 1999 2-3.5.1.
UPDATE 4/14/16: The ceiling tiles are not sealed around electrical panel "BL", leaving a gap of approximately 30" x 12". The interstitial space above the ceiling tiles is not provided with sprinkler protection.

Based on observation during the survey walk-through, the facility failed to install and maintain automatic sprinkler protection in accordance with the code. Lack of maintenance for fire protection system could result in delayed response of those systems to provide required protection.

Findings include:

A. At 2:45 PM on 5/13/2015, accompanied by the facility's Plant Operations Assistant Manager, Associate General Counsel, and Quality Specialist, on the Lower Level of the East Building in the Nuclear Medicine Department, the Break Room and Office were observed to not be furnished with a finished ceiling and the sprinkler heads were observed to be located more than the 12 inches below the floor structure above, which does not comply with NFPA 13 1999 5-6.4.1.1.

B. At 8:43 AM on 5/14/2015, accompanied by the facility's Plant Operations Assistant Manager, Associate General Counsel, and Quality Specialist, on the Lower Level of the West Building in Room W009, which is sprinklered, the ceiling was observed to have holes through the plaster, which does not comply with NFPA 13 1999 5-6.4.1.1.

C. At 8:50 AM on 5/12/2015, accompanied by the facility's Plant Operations Assistant Manager and Quality Specialist, in an alcove on the sixth floor of the East Building near Room E605, two sprinkler heads were observed that are closer than 6 feet together, which does not comply with NFPA 13 1999 5-6.3.4.

Based on direct observation during the survey walk-through, accompanied by facility staff, not all rooms are provided with sprinkler protection installed and maintained. This deficiency could affect patients, staff, and visitors if a fire is not quickly extinguished and spreads to other areas of the facility.

Findings include:

At 9:47 AM on 5/14/2015, accompanied by the facility's Plant Operations Assistant Manager and Quality Specialist, on the second floor of the Wyman Building in the Addiction Unit Storeroom, the suspended ceiling tile system was observed to be interrupted to allow the roof access ladder to pass through and the well is not enclosed. The space above the suspended ceiling is not sprinklered. This condition does not comply with with NFPA 13-1999 5-6.4.1.1.

Based on observation during the survey walk-through, the facility failed to install and maintain automatic sprinkler protection in accordance with the code. Lack of maintenance for fire protection system could result in delayed response of those systems to provide required protection.

Findings include:

A. At various times during the survey walk through, accompanied by the facility's Plant Operations Assistant Manager and Quality Specialist, in multiple locations in the East Building, sprinkler heads were observed that had shreds of blue plastic tangled in the deflector, which does not comply with NFPA 25 1998 2-2.1.1. Examples include:

1. Corrected 4/14/16
2. Corrected 4/14/16
3. At 9:55 AM on 5/12/2015 - Soiled Utility 450, fourth floor.

Ventilation systems are not maintained in accordance with applicable standards. Failure to maintain the integrity of protective features within the ventilation system can result in building occupant's exposure to harmful fire and smoke conditions.

Findings include:

A. Based on direct observations, staff interview and review of the facility ' s fire, smoke and fire/smoke damper inventory and latest inspection, the facility failed to maintain the HVAC system fire and smoke barrier protective devices in compliance with NFPA 90A, 1999. The inventory and inspection document dated April 11, 2014 as well as surveyor direct observation indicate the lack of access doors to inspect and service the protective device installed within the ventilation ducts. Improper installation and a means to inspect and service these protective devices can allow products of combustion to pass through the barrier the device is installed to protect.


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Based on direct observations and interview, the facility failed to maintain the HVAC system and does not comply with the requirements of NFPA 90A and / or ASHRAE.
Throughout the building that fire dampers, smoke dampers and combination fire/smoke dampers do not appear to be installed in compliance with their listings for the opening they are protecting. The findings include lack of access panels for inspection and maintenance, lack of installed retention flanges to hold the protective device within the opening it is protecting and in some installations the annular space for expansion has been sealed with what appears to be intumescent fire caulking.
Improper installation can allow products of combustion (smoke, heat and flames) to pass through a barrier of protection and this deficient practice could affect all residents in the entire building, as well as an indeterminable number of staff and visitors, if a fire were to occur and spread due to fire/smoke dampers not being properly maintained and inspected.
Findings include:

B. At 8:55 AM on May 12, 2015, a duct which penetrates the ventilation shaft near the Soiled Utility Room of the Second Floor, north end was observed to lack a fire damper and no access panel was installed as required by NFPA 90A 1999 3-3.2.

C. At 9:00 AM on May 12, 2015, the required smoke barrier wall located in a partially sprinklered smoke compartment was observed with gaps that are not sealed tight above the double egress door north eastside of the Second Floor.

D. At 9:10 AM on May 12, 2015, the surveyor observed conduit/wire penetration that are not sealed at the Second Floor smoke barrier wall between Clean Utility Room and the Nurse Station.

E. While accompanied by the Director of Plant Operations, Safety Officer and the Building Engineer, the surveyor observed fire dampers without sleeves or collars and retaining angles for compliance with UL 555 as required by NFPA 90A 3-4.1, 19.3.1.1, 8.2.3.2.4.1. Locations observed include:

1. At 8:55 AM on May 12, 2015, Second Floor duct penetrations throughout the designated 2-hour fire rated shaft enclosures.

2. At 11:10 AM on May 12, 2015, First Floor duct penetrations through 2-hour fire rated exit stair enclosures of Stair#11 and Stair #12.

F. At 10:55 AM on May 12, 2015, the Life Safety Plan indicates a ventilation shaft between the Soiled Utility Room and Nurse Station of the Second Floor that appears to contain a duct which serves the south end of the North Building. Due to the improperly installed access panel from the soffit of the Nurse Station, the required access panel for the shaft is blocked, hard to access and the surveyor was unable to determine whether or not a fire damper is installed and maintained to comply with NFPA 90A 1999.

G. At 11:20 AM on May 12, 2015, the Elevator Equipment Room at the north end Lower Level, there are large ducts that penetrate through the designated two-hour fire rated enclosure of this room. Fire dampers and fire damper access panels were not found.

H. At 11:30 AM on May 12, 2015, the Life Safety Plan indicates a two-hour fire rated separation between the North Building and the Tunnel on the Lower Level. The surveyor observed duct penetrations equipped with fire/smoke dampers that are not UL design assembly and not installed in accordance with NFPA 90A and/or ASHRAE.

I. At 9:00 AM on May 13, 2015, Lower Level, conduits, wiring penetrations are observed that are not fire sealed, located above the double doors leading to the tunnel and to the North Building.

Ventilation systems are not maintained in accordance with applicable standards. Failure to maintain the integrity of protective features within the ventilation system can result in building occupant's exposure to harmful fire and smoke conditions.

Findings include:

A. Based on direct observations, staff interview and review of the facility's fire, smoke and fire/smoke damper inventory and latest inspection, the facility failed to maintain the HVAC system fire and smoke barrier protective devices in compliance with NFPA 90A, 1999. The inventory and inspection document dated April 11, 2014 as well as surveyor direct observation indicate the lack of access doors to inspect and service the protective device installed within the ventilation ducts. Improper installation and a means to inspect and service these protective devices can allow products of combustion to pass through the barrier the device is installed to protect.

Based on observation during the survey walk through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

A. At 10:38 AM on 5/12/2015, accompanied by the facility's Plant Operations Assistant Manager and Quality Specialist, on the second floor of the East Building in the OR Corridor, access to Stair 5 from the corridor was observed to be partially blocked with chairs, which does not comply with 7.1.10.2.1.

Based on observations made during the survey walk through while accompanied by the Assistant Director of Plant Operations and the Director of Security, the surveyor found that the generator installation did not meet all of the requirements of NFPA-110. This could affect all occupants of the building if the generator does not operate during the loss of normal power.

Findings include:

A. On Wednesday, May 13, 2015 at approximately 11:00 AM the surveyor observed that the 500 kW plant operations generator and the acute care generator were not equipped with remote manual stop stations in accordance with NFPA-110, Section 3-5.5.6.

Based on observations made during the survey walk through while accompanied by the Assistant Director of Plant Operations, and the Director of Security the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. The building was equipped with enough transfer switches for each branch of emergency power, but several of the panels served from the branch transfer switches were serving mixed loads as shown by some of the following examples:

1. The surveyor observed at approximately 8:45 AM on 5/12/15 that critical panel W6-2EM in room W630 was serving a mixture of life safety, critical and some small equipment that are required by the 1999 edition of NFPA-70, Sections 517-30 through 517-35 to be separated into three separate branches.

2. The surveyor observed at approximately 9:50 AM on 5/12/15 that critical panel 3L6N-EM in room 348 served a mixture of life safety, (fire alarm), critical and equipment loads, (circulating pumps), that are required by the 1999 edition of NFPA-70, Sections 517-30 through 517-35 to be separated into three separate branches.

3. The surveyor observed at approximately 10:30 AM on 5/12/15 that life safety panel 2LS-1W served a mixture of life safety, and critical loads, (PIX, computer and nurse's station), that are required by the 1999 edition of NFPA-70, Sections 517-30 through 517-35 to be served from separate branches.

4. The surveyor observed at approximately 11:15 AM on 5/12/15 in the emergency department electrical room that critical panel 1L5N-EM was serving some life safety loads, (exit lights and med gas alarms), and normal panel LP-1CA had two breakers listed as serving fire alarm circuits that are required to be served from the life safety branch of emergency power.

5. The surveyor observed at approximately 9:45 AM on 5/13/15 that critical panel AC2EM3 in the east building second floor electrical room was also serving some equipment which does not comply with the 1999 edition of NFPA-70, Sections 517-30 through 517-35.

Based on observations made during the survey walk through, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

A. On 05/12/2015, while accompanied by the Plant Operations and Building Engineer, the surveyor observed that the electrical panels lacks accurate panel directories to comply with NFPA 70 1999, Section 384-13.

Locations include:

1. At 8:50 AM, Second Floor, north end, Example: Electrical Panel 2L61.

2. At 10:15 AM, First Floor, Electrical Panel (LP1EM2): located across Patient Room 125.

Based on observations made during the survey walk through while accompanied by the Assistant Director of Plant Operations and the Director of Security, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

A. On the morning of 5/12/15 while walking through all of the different elevator equipment rooms the surveyor observed that the elevator cab lights for all elevators were not served from a disconnect within the elevator equipment rooms served from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32, and elevator section 620-53.

B. At approximately 8:55 AM on 5/12/15, the surveyor observed that the endoscopy recovery area was not equipped with critical receptacles, and at approximately 8:30 AM on 5/13/15 the surveyor observed that the patient room headwalls on the fifth and sixth floors of the east building were not equipped with critical power receptacles to meet the requirements of NFPA-70, Section 517-18, and 517-19.

C. Corrected 4/14/16.
D. Corrected 4/14/16