HospitalInspections.org

Based upon observations there is damaged or missing fire proofing, openings in fire rated assembles that are not repaired, fire rated roof ceiling and floor ceiling assemblies that are not maintained, and penetrations that are not fire stopped to maintain the required fire resistance ratings of the assemblies.

Findings include
Around 11:00 PM on 11/7/16 it is observed that there are openings in plaster ceiling of the fire rated floor ceiling assembly in office space in the basement.

Around 11:24 PM on 11/7/16 it is observed that openings in plaster ceilings and penetrations through the fire rated floor ceiling assembly at various locations in the basement.

Around 11:30 PM on 11/7/16 it is observed that there is a damaged fire rated access in the ceiling above panel XLA-500 in the basement.

Around 11:24 PM on 11/7/16 it is observed that openings in plaster ceilings and penetrations through the fire rated floor ceiling assembly in the boiler room.

Around 12:10 PM on 11/7/16 it is observed that exposed bare steel to column in respiratory waiting room that is not fire proofed.

Around 12:29 PM on 11/7/16 it is observed that there is missing fire proofing at top of beam above ceiling at smoke barrier by information desk.

Around 1:10 PM on 11/7/16 it is observed that the fire rated roof ceiling assembly is not complete. There is missing fire rated ceiling tiles around the light fixtures in laboratory.

Around 1:16 PM on 11/7/16 it is observed that there is not a fire damper in the exhaust duct for bathroom.

Between 1:16 PM and 1:34 PM on 11/7/16 it is observed that there is a fire rated roof ceiling assembly and the supply grills do not have any fire dampers installed in the ceiling and return air plenum ceiling.

Around 1:56 PM on 11/7/16 it is observed that there is a fire rated roof ceiling assembly and the steel pipe at exit door between ER and OR is not fire stopped with a listed design and product.

Around 2:05 PM on 11/7/16 it is observed in x-ray admitting that there are light fixtures and the fire rated roof ceiling assembly is not installed around the light fixtures according to the listed design.

Around 3:02 PM on 11/7/16 it is observed that missing fire proofing on beams clips, behind conduit and behind junction boxes in exam room 1 in pain management.

Based upon observations there are items that are installed on the doors that restricts the full operation of the doors so occupants can egress to an exit.

Findings include
Around 2:30 PM on 11/7/16 it is observed that the double doors to pain management is equipped with a magnetic locks and all of the items are not associated with the door. Door is to remain unlocked until all items are corrected.

Around 2:53 PM on 11/7/16 it is observed that the 2:53 there is a push button dead bolt lock to clean utility in PREOP in PACU that requires two operations to unlock the door.

Around 4:21 PM on 11/7/16 it is observed that there are doors in the egress path in the basement of the three story wing that are locked in the means of egress.

Around 5:25 PM on 11/7/16 it is observed that there is slide bolts on or doors in the basement of the three story wing.

Based upon observations hazardous areas are not maintained to provide required separation and or fire resistant ratings for the hazardous areas. There are doors that are not self closing and latching, are damaged and doors that do not have the required listing for door hardware that could allow smoke and hot gasses to pass through the doors.

Findings include

Around 10:30 PM on 11/7/16 it is observed that there are penetrations of duct, conduit and electrical cable that is not fire stopped with a listed design and product in the basement.

Around 11:15 PM on 11/7/16 it is observed that the storage room medical records in basement is less than a 100 square feet and greater than 50 square feet and the room is not constructed as smoke partitions with self closing and latching door.

Between 11:19 AM and 11:24 AM on 11/7/16 it is observed that there are penetrations of fire rated assemblies that are not fire stopped with a listed design and product in the bio hazardous storage room.

Around 12:53 PM on 11/7/16 it is observed that the door closer has been removed from door to the storage room that is over 100 square feet and door is not a rated door. The room and is part of the fire rated smoke barrier wall in the old pharmacy.

Around 2:10 PM on 11/7/16 it is observed that the fire rated storage room door was not self closing and latching to storage room over 100 square feet by operating room.

Around 4:00 PM on 11/7/16 it is observed that door has no door closer to the storage room across from patient room 209 and is not self closing.

Around 4:54 PM on 11/7/16 it is observed that custodian room door is not self closing and latching.

Based upon observations of laboratories areas are not maintained to provide required separation and or fire resistant ratings for the hazardous areas.

Findings include

Around 1:00 PM on 11/7/16 it is observed penetrations in the fire rated wall above the door to laboratory that is not fire stopped with a listed design and product.

Between 1:10 PM and 1:16 PM on 11/7/16 it is observed that a hole in the fire rated wall by the bathroom that is not fire stopped with a listed design and product.

Based upon observation the kitchen equipment is not located in the correct position to provide proper coverage of the suppression systemd to capture grease laden vapors and to maintain the equipment in the correct position under the hood.


Findings include
Between 1:30 PM and 4:00 PM on 11/4/16 during review of the kitchen hood suppression system tests and inspection reports dated 8-4-16 notes that the nozzles are 2 part and needs to be replaced.

Around 4:56 PM on 11/7/16 it is observed that kitchen equipment is not in the correct position under the fire suppression nozzles and there is no device to maintain the equipment that are on wheels in the correct position under the suppression nozzles. The kitchen edge of the kitchen equipment is not located at least six inches from the inside edge of the hood.

Based upon observations of the fire alarm system there are areas where the required smoke detection and audible/visual notification devices are not installed according to NFPA 72.

Findings include
Between 1:42 PM and 1:56 PM on 11/7/16 it is observed there is an on call room in emergency and there is no smoke detector and audio visual fire alarm notification device in the room.

Around 4:03 PM on 11/7/16 it is observed that is an on call room in the three story wing and there is no smoke detector and audio visual fire alarm notification device in the room.

Based upon observations of the sprinkler system there is a system that has not been installed according to NFPA 13.

Findings include

Around 4:30 PM on 11/7/16 it is observed that sprinkler control valves for the glycol sprinkler system are not monitored by fire alarm system. There is no sign on, or at the door noting that there are sprinkler control valves located inside the room. There is no means to provide heat in the room above 40 degrees for the sprinkler system in the small generator room.

Based upon observations of the sprinkler system the required maintenance of the system is not being maintained.


Findings include
Between 1:30 PM and 4:00 PM on 11/4/16 during review of the sprinkler quarterly inspection report dated 9-21-16 noted that the antifreeze system's valve was closed and the technician opened the valve. The system was installed in December of 2015. There is no documentation for the system, no permit and backflow certification and, the valves are not supervised by the fire alarm system.

Between 1:30 PM and 4:00 PM on 11/4/16 during review of their documents, there is no documentation noting that the water tank is tested and inspected according to NFPA 25.

Between 11:19 AM and 11:24 AM on 11/7/16 it is observed that the sprinkler head shows sign of leaking in bio hazardous storage room.

Around 12:39 PM on 11/7/16 it is observed that there are no sprinkler control valve signs attached to the ceiling grid near pharmacy noting that there are sprinkler control valves above the ceiling.

Around 2:53 PM on 11/7/16 it is observed that there is a sprinkler escutcheon missing in closet across clean utility room PREOP in PACU.

Around 3:58 PM on 11/7/16 it is observed that there are openings in the ceiling tiles in class room on the third floor.

Based upon observations of all corridor doors there are doors found that did not have positive latching that could allow smoke to pass through the doors.

Findings include

Between 1:34 PM and 1:56 PM on 11/7/16 it is observed that there is a stretcher that obstructs the corridor door from closing and latching in emergency room.

Around 2:54 PM on 11/7/16 it is observed that there are corridor sliding doors requires more than 5 lbs. of force to open the door in PREOP in PACU.

Around 3:38 PM on 11/7/16 it is observed that bed obstructs corridor door to patient room 116 from closing and latching.

Based upon observations the fire rated smoke barrier walls have penetrations, joints and openings that are not fire stopped and could allow smoke to pass from one side of the smoke barrier to the other side.

Findings include
Around 12:05 PM on 11/7/16 it is observed that joint at the top of the fire rated wall above the smoke barrier doors by admin is not fire stopped with a listed design and product.
Around 12:22 PM on 11/7/16 it is observed that observed that joint at the top of the fire rated wall is not fire stopped with a listed design and product in main waiting.
Around 12:22 PM on 11/7/16 it is observed that observed that joint at the top of the fire rated wall is not fire stopped with a listed design and product top by information desk.
Around 3:02 PM on 11/7/16 it is observed that there is a penetration of the fire rated wall above the door that is not fire stopped with a listed design and product in pain management.

Based upon observations the smoke barrier fire rated doors have gaps between the door and the astragal that could allow smoke to pass through the doors observed at one out of three smoke barrier doors.

Findings include
Around 2:28 PM on 11/7/16 it is observed that the fire rated smoke barrier double doors to pain management has astragal that does not overlap the door and the gap is greater than 1/8 inches.

Between 2:30 PM and 2:53 PM on 11/7/16 it is observed that the fire rated smoke barrier double doors to PACU has astragal that does not overlap the door and the gap is greater than 1/8 inches.

Based upon observations the combustion air to a gas fire appliance is not from the outside.

Findings include

Around 4:37 PM on 11/7/16 it is observed that the combustion air damper is not connected in kitchen water heater room and is closed.

Based upon observations rubbish and laundry chutes are not maintained to provide required separation and or fire resistant ratings for the chutes. There are doors that have been modified.

Findings include
Around 3:45 PM on 11/7/16 it is observed that there is a linen chute door that has added punch lock and the frame has been modified near utility closet across from 104. This condition voids the listing of the linin chute door.

Based upon observations the electrical systems and equipment is not being maintained.

Findings include
Around 10:40 PM on 11/7/16 it is observed that there is an opening in an electrical panel where breaker is missing in panel and open at top to panel LA700. There is conduit and MC cable that is not supported properly. There are open junction boxes and mc cable. There is open wire that has been abandoned and not removed in main electrical room open.

Around 10:46 PM on 11/7/16 it is observed that there are Gould and Siemens breakers installed in a GE electrical panel XLA-400 in main electrical room. Only breakers that are listed for the panel are allowed to be installed in the panel.

Around 11:00 PM on 11/7/16 it is observed openings in junction boxes and there are light fixtures that are not supported above ceiling in the office space in the basement.

Around 11:19 PM on 11/7/16 it is observed that are open junction boxes and open wiring above the ceiling in the basement.

Between 11:19 AM and 11:24 AM on 11/7/16 it is observed that there are the light fixtures above ceiling and the of electrical cable is not supported properly in office area in basement physician services.

Between 11:19 AM and 11:24 AM on 11/7/16 it is observed that there is an open junction box in the bio hazardous storage room.

Around 11:25 PM on 11/7/16 it is observed that there is open wiring in the room under stairway in the basement.

Around 11:26 PM on 11/7/16 it is observed that there is a non-approved breaker tie for a double pole breaker in panel LA-800 in the basement.

Around 11:39 PM on 11/7/16 it is observed that is an opening in electrical panel PA-100 in boiler room.

Between 11:39 AM and 11:53 AM on 11/7/16 it is observed that the support of electrical cable is supported by conduit in boiler room.

Around 11:53 PM on 11/7/16 it is observed that support of electrical and box is above ceiling by egress door to corridor on the first floor.

Around 11:58 PM on 11/7/16 it is observed that there are electrical cables above ceiling in admin area that are not supported properly.

Around 12:18 PM on 11/7/16 it is observed that there is an open junction box above door to admitting in waiting area.

Around 12:29 PM on 11/7/16 it is observed that there is electrical cable above the ceiling that is not supported properly by information desk.

Around 12:35 PM on 11/7/16 it is observed that there is NMB electrical cable (Romex) that is tied to open junction box above ceiling at volunteer services. Romex is not allowed in this building as permanent wiring. There is electrical cabling that is not supported properly.

Around 1:34 PM on 11/7/16 it is observed that there is an open junction box and the electrical cables are not supported properly above the ceiling near room 5 in the emergency room.

Around 2:05 PM on 11/7/16 it is observed in x-ray admitting that there is electrical cable that is not supported properly above the ceiling.

Around 2:10 PM on 11/7/16 it is observed that there is flexible rubber cord that is located above the ceiling at double doors by operating room.

Between 2:10 PM and 2:28 PM on 11/7/16 it is observed that there is an open junction box and electrical cables that are not supported properly at the double cross corridor doors by pain management.

Between 2:30 PM and 2:53 PM on 11/7/16 it is observed that there is an open junction box above ceiling at double doors in PREOP in PACU.

Around 2:56 PM on 11/7/16 it is observed that open junction box above ceiling near room 6 in PREOP in PACU.

Around 3:24 PM on 11/7/16 it is observed that there are electrical panels that are in the fire rated CMU wall and the wall is not constructed around the panels to provide a one-hour fire resistant rating. There are joints and penetrations of the fire rated wall that are not fire stopped with a listed design and product of the new storage room.

Around 3:24 PM on 11/7/16 it is observed that there is a junction box that is not supported properly above the ceiling of the new storage room.

Around 4:14 PM on 11/7/16 it is observed that there are circuits on the life safety branch that are not allowed in panel XLAg100 in basement of electrical room 3 story wing.

Around 4:28 PM on 11/7/16 it is observed that XLA- 200B life safety branch electrical room small generator has circuits that are not allowed to be supplied from the Life Safety Branch of the emergency electrical system.

Around 4:46 PM on 11/7/16 it is observed that there is an opening in panel XPA-100 life safety branch that are not closed.

Around 4:46 PM on 11/7/16 it is observed that there are circuits that supply items that are not allowed to be supplied from the life safety branch of the emergency electrical system.

Around 4:50 PM on 11/7/16 it is observed that there is an opening in electrical panel EDP.

Around 5:02 PM on 11/7/16 it is observed that the solenoid for the gas shut off has open wires in the kitchen.

Based upon review of documentation there is not complete documentation of the testing and inspection of the emergency generator according NFPA 110.

Findings include

Between 1:30 PM and 4:00 PM on 11/4/16 during review of the generator inspection reports for generator1 and 2 all the required information was not in the documentation as required by NFPA 110.

Based upon observations, the electrical systems and equipment is not being inspected and tested.

Findings include
Around 3:30 PM on 11/7/16 it is observed that a medical plug strip was in use in the infusion office and, there is no inspection and test reports available at time of survey for the plug strip.

Based upon observations the outdoor med gas storage room is not constructed according to NFPA 99.

Findings include

Around 4:42 PM on 11/7/16 it is observed that ventilation of med gas storage room is not according to NFPA 99. The wall fans are not supplied electric power with a secondary power from the emergency backup electrical circuits.