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Based on observation and interview, the facility did not provide and maintain the required building construction type with a compliant type of construction, support steel covered with rated fire proofing and sealed floor penetrations. This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 4/9/2013 at 9:20 am surveyor observed on the Level 1 floor in the Corridor 1595 along smoke compartments wall 1-W-1 & 1-SW-1, that the building's construction type was not compliant for the number of floors of a health care occupancy. The facility was built with wood above the ceiling at this location and does not meet the NFPA 101 (2000 edition), Section 3.3.118 Limited Combustible requirements criteria. The construction is Type I (332), non-combustible, 5-Story Building. This observed situation was not compliant with NFPA 101 (2000 edition), Table 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities ).



29942

Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing, and support steel covered with rated fire proofing. This deficiency occurred in 2 of the 3 smoke compartments, and had the potential to affect 30 of the 50 staff that were working.

FINDINGS INCLUDE:
1. On 4/11/13 in the afternoon surveyor observed in the SC-2 smoke compartment on the 2nd Floor in the Storage Shell Space, that 2-hour fire-proofing was missing from the structural steel beams and at the 2-hour fire separation wall to adjoining Business Occupancy and where the two floors (1st & 2nd)meet at the exterior wall assembly. The 2-hour fire-safing with intumesent fire-spray was observed 'missing' along the entire exterior perimeter wall at thefloor line where the wall was opened-up due to recent water damage. The Construction Building Type is 1B (222). This observed situation was not compliant with NFPA 101 (2000 edition)38.1.1.1(1), 1.4.1, 38.1.4, 38.1.2, 38.1.6, 38.3.1, 38.3.2, 8.2.5 & 8.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (Satellite Clinics Property Manager) , staff M1 (Director of Facilities)and staff M2 (Manager of Facilities).



28616

Based on observation and interview, the facility did not provide corridor separation doors with self-latching inactive doors, and positive-latching hardware. This deficiency could affect 1 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 04/09/2013 at 9:45 am surveyor observed on the Level 1 floor in the OR #12 (double leaf) and Ante-Room Door #12, that the corridor doors would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

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Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings, rated wall construction, compliant vertical opening, ducts in rated walls with fire dampers, sealed wall penetrations,rated doors, rated wall construction, and ducts in rated walls with fire dampers. This deficiency could affect 20 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/10/2013 at 9:15 am surveyor observed on the Level 1 floor in the Exit Passageway 1789, 2-Story Space at West Entrance & Exit Passageway 1790, that the vertical shaft wall was not compliant. Observed multiple penetrations in 2-hour fire-rated walls at both Exit Passageways above ceilings and at the 2-Story West Entrance due to repairs being made to the assembly. A 2-Story space in a hospital is required to be fire-rated to 2-hour and found the Won-Door separating the Level-1 from Level-2 to be only fire-rated to 1-hour. The Won-Door is non-compliant and is in process of being removed as part of the correction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1(Director of Facilites)and staff M2 (Manager of Facilities).

2. On 04/10/2013 at 2:25 pm surveyor observed on the Level 1 floor in the Stair 22, that the shaft enclosure walls making up part of the stair and chase were not constructed to have a 2-hour fire resistance rating because when looking inside the shaft near Door 124, the concrete masonary block was observed with large chunks of block missing and not fire-sealed properly to meet a UL approved tested assembly for this application. Stair 22 'chase wall' was not built to a 2-hour fire rating. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Facilities Director)and staff M2 (Manager of Facilities).
FINDINGS INCLUDE:

3. On 04/10/2013 at 3:00 PM surveyor observed on the Level-4 floor in the Visitor Lounge 4766A, that the shaft enclosure wall and windows were not constructed to have a 2-hour fire resistance rating because walls separating the atrium from corridor are not rated. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).

4. On 04/10/2013 at 3:30 pm surveyors observed on the Lower Level floor at Stairwell 45, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because exterior windows (which are not rated) were 5 feet from exterior ducts, this area was under construction. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities)and staff M2 (Manager of Facilities).

5. On 04/10/2013 at 3:15 pm surveyor observed on the Level 5 vertical shaft enclosing wall assembly could not be verified of having the required rating. Non fire-rated tempered glass windows assemblies enclosed a 2-story space for a lower level winter garden. The window assemblies and adjoining walls did not contain the minimum fire rating for an equivalent vertical shaft (2-hour). The windows occurred in approximately 80% of the enclosing wall space adjoining Room 5769 and Corridor 5795. The vertical space was not designed as an Atrium and did not follow the provisions of 8.2.5.6. The applicable codes in effect for this 2003 addition required a 2-hour fire-rating of the wall to match the supporting floor 2-hour fire-rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, 8.2.5.4, 8.2.3.2 and 4.6.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).

6. On 4/11/2013 at 3:45 pm surveyor observed on the Lower Level floor in the Old Boiler Room (under the kitchen), that the kitchen exhaust duct and fire-wrap penetrated the floor assembly and were not properly fire-sealed from above or below the penetrations. This means the wall above, enclosing the kitchen exhaust ducts, is a vertical shaft. The floor assembly was not sealed according to approved listed testing agency design. The deficiency included several 36 inch by 12 inch exhaust ducts through the floor, not sealed per requirements of the floor assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1(Director of Facilities)and staff M2 (Manager of Facilities).
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29942

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with observable exit signs, "no-exit" signs at that may be confused as exits, and exit signs when the egress path is not readily apparent. This deficiency could affect 3 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/10/2013 at 11:19 am surveyor observed on the Level 1 floor in the Kitchen & Servery Suite, that the path of egress in the aisles/passages were not readily apparent and exit signs were not provided for clear direction to an exit out of the Food Production Area from the Kitchen towards the Servery, and the Servery was missing required exit signs leading to the exit access door, if the vertical gate were to be closed. Currently the vertical gate is not secured in an open position and lighting levels were low. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4 Exit Access & 7.10.1.7 Visibility. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).

2. On 04/10/2013 at 11:25 am surveyor observed on the Level 1 floor at the Old Kitchen Loading Dock 1042C, Old Compressor Room 1042A & Old Kitchen Storage Room 1042B , that the path of egress in the corridor/aisle/passage was not readily apparent and an exit sign was not provided yet near the required Exit and Exit Discharge, now under construction. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4 Exit Access & 7.10.1.7 Visibility. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).
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29942

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction, and taped joints on rated walls . This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/09/2013 at 1:58 pm surveyor observed on the Level 1 floor in the Smoke Barrier wall between Smoke Compartments 1-SW-1 & 1-SW-2 outside the Surgery Female Locker Room, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the top-of-wall of the upper smoke barrier wall above the ceiling was not fire-sealed per its UL listing. This smoke barrier is the dividing point between the Surgery Department and the Imaging Department. Per follow-up interview with staff M1 (Director of Facilities), this correction will be rolled-up into the Surgery Locker Rooms renovation project because physical access is so limited to top-of-wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities), staff M2 (Manager of Facilities)and staff M16 (Licensure & Accreditation Coord.).
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29942

Based on observation and interview, the facility did not enclose hazardous rooms with doors with positive-latching hardware, a smoke-tight room enclosure (in a sprinkled smoke zone), closer on all doors, fire-rated astragals, fire-rated walls in a non-sprinkled hazardous room, taped joints on fire-rated walls, and sealed wall and floor penetrations. This deficiency could affect 7 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/10/2013 at 11:35 am surveyor observed on the Level 1 floor in the Shell space that use tobe the Dining Room/Cafeteria, was now being used as a Storage Room and Pharmacy Training Room on Modular Pharmacy Dispensing Units. Observed one of the exit access doors was held open by a 'red' maintenance or tools bag. The door went to an Exit Passageway and the door was a 90 minute fire-rated door with closer. The door was prevented from self-closing. The Exit Passageway served many other parts of the building. Storage Rooms are required to have door closers to keep the door closed. Aisles within the Training Room were not a minimum of 44 inches in clear width to an exit access door due to excess debris littered over the entire floor area. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. In interview with staff M2 (Manager of Facilities), he stated he did not know this 'training activity' was occuring in this shell space, since it was part of the construction project to fix the Kitchen and Servery deficiencies. The Department of Health Services and Division of Quality Assurance were never informed of a Occupancy within this space, since it was made into a 'shell space', part of a construction project. For 'safety purposes' ALL storage items are to be removed from this room if it is to be continued used as a Training Room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).

2. On 8/9/2012 at 1:24 pm surveyor observed on the Lower Level floor in the Room B13, that penetration(s) were not sealed according to approved listed testing agency designs. The deficiency included two (1 inch) penetrations above the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager of Facilities).

3. On 04/09/2013 at 1:58 pm surveyor observed on the Level 1 floor at the Women's Surgery Locker Room 1129, that the enclosing wall was not constructed to a 1-hour fire resistance rating (space was under construction). The wall around the Women's Surgery Locker Room 1129 was not built to the required 1-hour construction, including 45-minute fire-rated doors with closers. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities), staff M2 (Manager of Facilities) and staff M16 (Licensure & Accreditation Coord.).

4. On 04/10/2013 at 4:54 pm surveyor observed and reviewed records on the Lower Level floor in the Material Management Room at Loading Dock that the enclosing wall was not constructed to a 1-hour fire resistance rating (wall was under construction). The interim life safety measures (ILSM)were not being followed for a construction space, dust protection barriers were not fully-encompassing from floor to floor deck above. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).

5. On 04/10/2013 at 4:00 pm surveyor observed and reviewed records on the Lower Level floor in the Old Boiler Room, that penetrations were not sealed according to approved listed testing agency designs. The deficiency included several holes in the floor where kitchen exhaust ducts pierced the floor assembly above, without proper sealing of the floor assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).
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29942

Based on observation and interview, the facility did not provide enclosures around exit stairs with closer on all doors, exit stairwells without openings to unoccupied rooms, and stairwell requirements. This deficiency could affect 8 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/09/2013 at 10:40 am surveyor observed on the Level-4 floor in the Stair 61, that an opening in an exit enclosure was from an Unoccupied Space. There was no vestibule in front of the Unoccupied Mechanical Penthouse equal to the stairwell, to provide additional Safety from fire, and this Mechanical Penthouse had direct access through the Stair 61 Enclosure. Stairwell 61 was under construction as part of the corrections. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and M2 (Manager of Facilities).

2. On 04/09/2013 in the morning, surveyor observed on the Sub-Basement Level floor at the Mezzanine B154 (near the Facility Engineering Offices), that an opening in an exit enclosure was from an unoccupied space. The deficiency included an Unoccupied Mezzanine B154 open to the Stair 46 enclosure. This vestibule project was still under construction at time of verification visit. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities)and staff M2 (Manager of Facilities).

3. On 04/09/2013 in the morning, surveyor observed on the Lower Level floor Exit Passageway B615 to Stair 81 in the Education Wing, that the Exit Passageway was not compliant. The Exit Passageway had Men and Women Locker Rooms opening onto the Exit Passageway. Locker Rooms are considered non-occupied spaces and depending on number of lockers, plus materials within the spaces could be considered hazardous. This area was to be corrected under CMS Corrections-Package 2 by removing the Exit Passageway designation and turning it into a corridor/aisle/passage open from Corridor B639. Per interview with staff M2 (Manager of Facilities) the wall and door assembly were to be removed opening this space up to Corridor B639. This existing observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. & reference 19.2.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).
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29942

Based on observation and interview, the facility did not provide and maintain the exit access travel distance to exits as with egress paths within the required travel distance . This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.


FINDINGS INCLUDE:
1. On 4/10/2013 at 8:03 am surveyor observed on the Level 1 floor in the Surgical Suite Area including; Clean Equipment 1644 & Great Equipment Room, that a travel distance from the corner of the inside of Electrical Room 1664 & Room 1666 to the closest exit door exceeded 150' from inside room to an exit. Currently this area is under construction to correct this deficiency. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.6 and 7.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities)and staff M2 (Manager of Facilities).

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Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path, compliant egress path , paths with sufficient headroom, paths that are maintainable in all weather conditions, doors that opened with under 50 pounds of force, and egress without passing through intervening hazardous rooms. This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/09/2013 in the morning, surveyor observed on the Level 1 floor in the Dumb Waiter Alcove off Corridor 1399 N, that the egress path was not compliant. The Alcove width is less than 32 inches. Section 19.2.3.3 Exception No. 1 (States): Aisles, corridors, and or ramps in adjunct areas not intended for treatment, or use of inpatients shall be not less than 44 inches in clear and unobstructed width. The area was under construction at time of verification visit to correct this deficiency. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2, 7.2, 7.5 and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities)and staff M2 (Manager of Facilities).

2. On 04/10/2013 in the afternoon surveyor observed on the Lower Level floor in Room B75G, Healing Gardens, that the exit discharge path did not have a maintainable surface. The path was composed of stone slabs with dirt in between. The surface is unstable and narrow. This area was under construction at time of verification visit. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities)and staff M2 (Manager of Facilities Officer).

3. On 04/10/2013 in the afternoon surveyor observed on the Lower Level floor in Room B75G, Healing Gardens, that the area was under construction to correct the citation that the door was locked from the egress side. The latch on the exit (wrought iron) gate did not work. Plans were submitted and approved with construction underway at time of verification visit. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities)and staff M2 (Manager of Facilities).

4. On 04/10/2013 in the afternoon surveyor observed on the Lower Level floor in Room B75G, Healing Gardens, that the egress path was not compliant. There are building windows (Old Doctors Lounge) along the exit path. If a fire was located in Doctor's Lounge, then there would not be a safe path to public way. Plans were submitted and approved with construction underway at time of verification visit. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.7, and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).
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29942

Based on observation and interview, the facility did not provide rooms, or patient sleeping suites, larger than 1,000 square feet with at least 2 remote exit access doors with and at least two exits from large suites. This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/10/2013 at 11:26 am surveyor observed on the Level 1 floor in the Kitchen & Servery Suite, that the suite of rooms were greater than 2,500 SF and the only exit egress through the Servery were through two existing vertical gates that are closed at off hours without a egress swinging side door. The other egress out of the Servery was through the Kitchen, which is considered hazardous and not allowed. One of the two vertical gates were not fully-secured in an open position as yet. The area was still under construction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5 Arrangement of Means of Egress, 19.2.5.1 thru 19.2.5.8 Suite of Rooms, and 7.5.1.2 & 7.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).

2. On 04/10/2013 at 11:28 pm surveyor observed on the Level 1 floor in the Old Kitchen Loading Dock 1042C, Old Compressor Room 1042A & Kitchen Storage Room 1042B , that the suite of rooms were greater than 2,500 SF and there was no code compliant exit egress to an exit. The access around the abandoned Elevator to Stairway 62 was less than 36 inches in clear width for a non-patient access route. The loading dock doors were vertical and did not meet the minimum requirements for egress per section 19.2.5. This area was under construction at the time of the verification visit. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5 Arrangement of Means of Egress, 19.2.5.1 thru 19.2.5.8 Suite of Rooms, and 7.5.1.2 & 7.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).
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Based on observation and interview, the facility did not provide code compliant smoke detection tied to the fire alarm system to required areas deemed hazardous. This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/09/2013 at 10:44 am surveyor observed on Lower Level floor in Stair 46 Vestibule, a smoke detector was missing. Smoke detector was part of the correction to the Stair 46 plan of correction. This observed situation was not compliant with NFPA 101 (2000 edition), section 18.3.2.1, 8.4.1.1, 18.3.4.1, 9.6 and per NFPA 72 (1999 edition), under new construction for a hazardous space vestibule.



29942

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition requirements, with non-sprinkled rooms that met permitted exceptions , sprinklers that were too far from the ceiling, sprinklers free of obstructions near the ceiling, with sprinklers at required exterior locations, matching response sensitivity, water flow free of wall obstructions, unobstructed water distribution and all rooms sprinkled when the code required the Building to be fully-sprinkled. This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/10/2013 in the afternoon surveyor observed on the Sub-Basement Level floor in the Corridor SB990, that the space was under construction and sprinkler heads were turned up for the construction, but not all areas were covered per NFPA 13 requirements. The sprinkler heads were blocked by plastic sheets used for particle containment in a construction area and ducts in some locations. This observed situation was not compliant with NFPA 13 (1999 edition), 5-3.1.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities)and M2 (Manager of Facilities).

2. On 04/10/2013 in the afternoon surveyor observed on the Lower Level floor in the Employee's Lounge Women's Locker Room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side obstructing item . The obstruction included the toilet stall panel This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager of Facilities).
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29942

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 1 of the 3 smoke compartments, and had the potential to affect 10 of the 50 staff that were working.

FINDINGS INCLUDE:
1. On 4/11/13 in the afternoon surveyor observed in the SC-LL smoke compartment on the Lower Level floor in the Storage Room #0006, that there was one or more unsealed holes near the ceiling. The holes included numerous 2" x 4" holes in the ceiling tile from water issues. These holes would reduce the response time of the sprinklers in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M3 (Satellite Clinics Property Manager), staff M1 (Director of Facilities)and M2 (Manager of Facilities).



28616

Based on observation, interview, and review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included regular facility inspections of hazardous spaces including areas still under construction per requirements of NFPA 101. The sprinkler system did not have intact escutcheon rings, and ceilings sealed above the sprinklers to collect heat. Many areas had the old metal ceiling pans with holes and perforations in the metal ceiling pans. This deficiency could affect 1 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/10/2013 at 11:35 am surveyor observed on the Level 1 floor in the Shell space that use to be the Dining Room/Cafeteria, was now being used as a Storage Room and Pharmacy Training Room on Modular Pharmacy Dispensing Units. Observed one of the acoustical ceiling tiles out. The hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).


29942

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with missing smoke damper, missing fire damper, plenum mechanical rooms free of storage, neutral airflow between the corridor and rooms, and flange & sleeve around fire damper. This deficiency could affect 14 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/10/2013 in the morning surveyor observed on the Level 1 floor in the Old Kitchen Loading Dock 1042C, that a fire damper was not installed in an air transfer duct that penetrated the rated floor assembly. Observed a duct that penetrated a the floor at the loading dock and was not fire dampered. The relief exhaust emptied directly onto the exit discharge to a public way. There should have been a 10 feet setback to the public pathway per HVAC Code. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager of Facilities).

2. On 04/10/2013 in the afternoon surveyor observed on the Lower Level floor in the old boiler room (below the Kitchen), that airflow between the corridor and this room did not appear to be neutral. The space is used as a Working Shop for metal bending and afixing metal protection pieces to doors, and storage of wood doors, pipes, miscellaneous building materials. There appears to be exhaust air and supply air to the space, but a HVAC Balance Report was not provided at the time of the verification visit exit. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities)and staff M2 (Manager of Facilities).
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29942

Based on observation and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96. This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/10/2013 in the afternoon surveyor observed on the Lower Level floor in the Old Boiler Room (below the Kitchen), that the Kitchen Hood Suppression System was not compliant. The 'fire-wrapped grease duct' was not sealed per manufactures instructions where the duct passes through the floor. It appeared there was a new fire-wrap, but the 'fire-wrap' was already damaged by materials being brushed against it. The 'fire-wrap' was not protected in a shaft or its layout in a location so as not to be tampered with, customary precaution as an Industry Standard. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.6, 9.2.3 and NFPA 96. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities)and staff M2 (Manager of Facilities).

2. On 04/10/2013 in the afternoon Surveyor could not verify the kitchen exhaust ducts were properly wrapped from kitchen hood to exterior of building in fire-rated insulation and meeting all the requirements of NFPA 96 as well as proper slope of horizontal duct above ceiling. Pictures were not provided how the 'fire-wrapping' was accomplished inside the Kitchen Hood Shaft, nor was any review accomplish by any Federal/State/Municipal Building Authority prior to closing-up any shaftwalls where the 'fire-wrapping' occurred. The opening of the shaftwall where the exhaust duct was traversing on 1st Floor in the Kitchen was not possible during the original survey and follow-up verification visit. The Kitchen is in 'active' operation. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.6, 9.2.3 and NFPA 96. The condition was confirmed at the time of follow-up 'record documentation interview' with staff M1 (Director of Facilities)and M2 (Manager of Facilities).
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29942

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, and proper labeling of pipes and cyclinders as required by NFPA 99. This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/10/2013 in the morning after 8 AM while touring the Surgery Department surveyor observed that medical gas piping was still not installed according to the requirements of the code, and the previous Annual Report did not show elements within the Annual Report corrected since January and June 2011. The previous Report was completed by Gary Canter, Tim Connell & Steve Knezic of Med Gas Solutions, Franklin, WI 53132. Items identified in the Annual Report included Zone Valves at OR 11 and NICU. The piping installation was missing directional arrows at most Zone Valves and some piping above the ceiling at many areas on Level 1 Surgery areas. Another Annual Report was produced by Clark Zeit-Inspector, for Medical Technologies Associates, December 19-23, 2011. This report identified the following rooms; OR 15 & OR 16 having leaks with no confirmation the leaks were fixed. These OR's were under construction during the verification visit. 1999 (edition) NFPA 99, section 4-3.1.2.3(b)(d) shutoff valve. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and 1999 (edition) NFPA 99, section 4-3.1.2.3(b)(d) shutoff valve. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager of Facilities).


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Based on observation and interview, the facility did not provide and maintain combustibles at least 50 feet away from a 1000 gallon or greater liquid oxygen tank, 25 feet away from 1000 gallon tank or less liquid oxygen, did not provide proper labeling of the medical gas pipes & did not provide medical gas piping as required by NFPA 99 and per NFPA 101, Chapters 18 & 19. These deficiencies could affect 6 of the 80 smoke compartments in the Buildings and numerous staff and visitors evacuating the building via protection to the Public Way.

FINDINGS INCLUDE:
1. On 04/10/2013 in the morning just before 12-Noon surveyor observed the bulk oxygen tank near the Old Kitchen Loading Dock, that combustibles like shrubs and other combustible things were within 50 feet of the Oxygen Tank, greater than 1000 gallons. Items besides trees & shrubs were plastic fencing. It was learned upon walking into the locked space that Pharmacy Modular Dispenser Training is occurring in the (vacated) Cafeteria. This observed situation was not compliant with NFPA 50 (1998 edition) section 2.2.4 and NFPA 99 section 4-3.1.1.2(a) 10 b. The condition was confirmed at the time of discovery by concurrent observation and discussion about the shrubs and fence during interview with staff M1 (Director of facilities)and staff M2 (Manager of Facilities).

Based on observation and interview, the facility did not provide a code compliant environment with miscellaneous deficiencies, did not meet limited combustibility requirements, did not provide a code compliant environment with two exit access from a room or suite of rooms, and did not provide suite travel distance under the required limits. This deficiency could affect 9 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/10/2013 in the morning just before 12 noon surveyor recalled the non-HVAC-balance on the Level 1 floor in the Dishwashing Room 1036, Kitchen 1040 & Servery 1041. Documentation was not provided at time of Verification Visit Exit, to show the entire Kitchen, Old Serving and Old Cafeteria were balanced to the adjoining East-West Corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.7 and installed per NFPA 90A & B (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).

2. On 04/10/2013 in the morning surveyor observed on the Level 1 floor in the Lab Testing Center, that the Lab Testing Center (LTC) is open to the 2-Story space and all areas are not easily visible from all areas within a 2-Story space. The 2-Story Space does not meet Atrium requirements since there is no 'smoke evacuation system' present. The LTC does not meet normal corridor access requirements since at least one area is exposed to the 2-Story Space (shaft), not allowed to be a Exit unless it meets Atrium requirements. The Lab Testing Center should be separated from the 2-Story Space by 2-hour fire-rated construction. Currently perimeter glass panels with 1/4 inch vertical openings are exposing the LTC to the 2-Story Space. Observed this space under construction to correct these deficiencies. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.7 and installed per NFPA 90A & B (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).

3. On 04/10/2013 in the morning surveyor observed on the Level 1 floor in the Exit Passageway 1793 from Stairs 101 + Stairs 31 & Stairs 33, that the heating ventilation and air conditioning for this space is required to be independent from other areas of the hospital per references in the State Licensing Code (DHS-124) and State (Safety & Professional Services) Commercial Building Code. The air is not balance between adjoining Smoke Compartments, Exit Passageway and the 2-Story Space based on air rushing past us at the fire-rated doors separating these spaces and not having seen the most recent HVAC Balance Report for these areas. Observed these spaces were under construction to correct these deficiencies. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.7 and installed per NFPA 90A & B (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

4. On 04/10/2013 in the morning just before 12 noon surveyor observed on the Level 1 floor in the Old Cafeteria, that 'ANY' alteration or renovation shall meet, as nearly as practicable, the requirements for new construction. If the alteration, renovation, or modernization adversely impacts required life safety features, additional upgrading shall be required. Upon entering the space, assuming it was suppose to be a 'shell space' as identified on the architectural drawings and not occupied by anyone, observed several persons within the space Training staff on new modular pharmacy dispensers and space was being used for hazardous storage. This is not allowed per DHS 124 Licensing requirements and not allowed per the 2000 NFPA 101, which requires hospitals and health care facilities to be built to the minimum 'definition' of Section 3.3.118 for Limited Combustibility and in compliance to 42 CFR 482.41 Condition of Participation: Physical Environment. This observed situation was not compliant with NFPA 101 (2000 edition), Section 4.6.7 and Section 3.3.118. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).

5. On 04/10/2013 in the afternoon am surveyor observed on the Lower Level floor in the Endoscopy Suite, that the travel distance of 100 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.8. this space is under construction. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager of Facilities) and staff M1 (Director of Facilities).

6. On 04/10/2013 in the afternoon surveyor observed on the Lower Level floor in the Room B971 (Engineering Suite), that the travel distance of greater than 69 feet through (2) intervening rooms exceeded the maximum of 50 feet in a Non-Sleeping Suite. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.8. Plans were submitted and approved for construction. This space was under construction. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).
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29942

Based on observation and interview, the facility did not provide existing elevators with proper 'firefighter controls' with elevators that were accessible with fire fighters service. This deficiency could affect 6 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 04/10/2013 in the afternoon surveyor observed on the Level 1 floor in the Exit Passageway & Elevator Lobby 1793, that the elevator traveled greater than 25 ft above/below the level of building entry and did not have firefighter service capability, unfortunately it opened into a space less than 2 feet in depth because the fire and smoke system would close the Won-Door in front of these Elevators. The Elevators 'fire recall' should be located to another floor level or relocate the Exit Passageway around the Elevator Lobby. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.3, 9.4.3.2, and ANSI A17.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M2 (Manager of Facilities).

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