State fire marshal's report on Carilion Roanoke Memorial Hospital's fire safety violations

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(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

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PRINTED: 07/21/2009FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

490024 01/21/2009

ROANOKE, VA 24033

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

CARILION MEDICAL CENTER1906 BELLEVIEW AVENUE

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

K 000 INITIAL COMMENTS K 000

East Building

Description of structure: 10 Story Building

Construction Type: Type II (222)

Sprinkler Status: Partially Sprinklered

An announced recertification Life Safety Code

survey was conducted 12/01/2008 - 12/19/2008 in

accordance with 42 Code of Federal Regulation,

Part 482: Conditions of Participation for Hospitals.

The facility was surveyed for compliance using

the LSC 2000 Existing regulations. The facility

was not in compliance with the Requirements for

Participation Medicare and Medicaid.

The findings that follow demonstrate

non-compliance with Title 42 Code of

Regulations, 482.41(b) et seq (Life Safety from

Fire.)

K 011 NFPA 101 LIFE SAFETY CODE STANDARD

If the building has a common wall with a

nonconforming building, the common wall is a fire

barrier having at least a two-hour fire resistance

rating constructed of materials as required for the

addition. Communicating openings occur only in

corridors and are protected by approved

self-closing fire doors. 19.1.1.4.1, 19.1.1.4.2

This STANDARD is not met as evidenced by:

K 011

Based on observations, the facility failed to

ensure that the fire barrier wall was maintained

between buildings.

Findings include:

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete NC5621Event ID: Facility ID: VA0511 If continuation sheet Page 1 of 67

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K 011 Continued From page 1 K 011

On 12/10/2008, at approximately 1440 hours, it

was observed that on the 9th Floor, there

are multiple penetrations through the Mountain

and East buildings rated separation wall that are

not properly fire stopped.


was observed that on the 8th Floor, what

is supposed to be a 2-hour fire barrier wall

separating the East and Mountain buildings does

not appear to be constructed as a 2-hour rated

assembly.


was observed that on the 8th Floor, the

double doors at the separation wall for the East

and West Pavilion do not appear to have the

proper rating for a 2-hour building separation.


was observed that on the 5th floor, in the

Dialysis area, the 2-hour separation wall between

Dialysis and the exit corridor to stairwell

5 is not complete. Sections of the block wall

above the 1 1/2-hour rated door are missing and

there are plumbing lines running through those

spaces.


was observed that on the 3rd floor, the

separation wall going into the Blood Bank area in

the corridor at the double fire barrier the

doors are rated 3/4-hour doors instead of 1 ½

hour rated doors. Also, the door frame is

labeled as being rated for 45 minutes.


was observed that on the 6th floor, at the


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separation between East and Mountain, directly in

front of the Vascular consultation room,

above the drop ceiling, there is an unsealed

penetration in the ceiling above. This area

appears to have a plenum ceiling.



separation between East and Mountain, at the

doors to Mountain, there are three penetrations in

the 2 hour fire barrier.

These violations have the potential to affect all

smoke compartments where they are located,

adjacent smoke compartments, and adjacent

buildings.

The above was witnessed by Department of

Engineering personnel.


Building construction type and height meets one

of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4,

19.3.5.1


K 012

Based on observations made, the facility failed to

ensure that the building construction type was

maintained.

Findings Include:


was observed that on the 10th Floor, in

the Mechanical room that there are multiple areas

missing the spray-on fire proofing. This fire


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proofing is not complete.


was observed that on the 7th Floor, in the corridor

next to stair #4 above the drop ceiling at electrical

panel L7B it was found there is a section of the

steel support structure that has had the spray-on

fire proofing removed.


was observed that on the 6th Floor, near

the double doors at the elevator lobby by the

Ladies' Restroom that the structural steel

beams and trusses above the drop ceiling were

not sprayed with fire proofing.



intermediate level Mechanical room above the 6th

floor has spray-on fire proofing incomplete in

many areas on the structural steel at the

mechanical beam clamp hangers etc.



small office next to Stairwell #5 was found to have

the spray-on fire proofing incomplete

on the beam clamp hangers on the structural

steel.



Mechanical Room by stair #5 that the steel

support beams structure on the overhead is

missing the spray-on fire proofing. The

mechanical hardware hangers and clamps have

not had the fire proofing completed.



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was observed that on the 5th floor, the small

Mechanical Room near stair #5 that goes into the

connector corridor between Mountain and East

has exterior fresh-air vents in it that have poly

sheeting up at the steel beam with spray-on

fireproofing over the poly sheeting. This is located

above the entry door.



Mechanical room at the Mountain building

connector corridor, just before entering into the

Mechanical room it was found there is plastic

sheeting up on the spray-on fireproofing beam, all

along the brick wall.



mechanical room near the entrance from the

corridor, has poly sheeting hanging down from

the overhead beam that's been coated with

spray-on fireproofing.



Dialysis area in the back by the Soiled Utility room

at the double fire-rated doors that the

wall does not appear to be complete above the

ceiling to the overhead decking. This wall is

indicated as a 2-hour rated wall on the fire

protection plan.


was observed that on the 5th floor, the

Mini Distribution storage area appears to have a

shaft with fire dampers going into it. It has a rated

access door that is not self-closing, and the shaft

construction does not appear to be complete.


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Mini Distribution area fire protection plans are not

indicating a smoke-rated wall separating it from

the corridor. This should be a smoke barrier or

possibly a 1-hour rated wall.



Mini Distribution area has above the ceiling near

the drain line, a 3" or 4" abandoned

drainpipe coming down through the overhead

deck from the floor above, and it is open

without proper fire stopping inside it.



Mechanical room has the spray-on fireproofing on

the overhead structural steel missing

over the mechanical connections hangers and on

the steel where the hangers connect.


was observed that on the 4th floor, above

the bulkhead at the vending machine area,

between family waiting and the vending machine

alcove, is a piece of wood planking that runs

across that bulkhead



exit corridor near the Information Desk and

throughout the area in this corridor, and back

near Patient Registration, the spray-on

fireproofing on the structural steel is incomplete.



Endoscopy lab, above the door between the two


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laboratories, has the wall marked as a fire

partition. There's a 10" to 12" diameter hole cut

through the sheet rock wall. There's only

one layer of 5/8 sheet rock on one side of the fire

partition. The doors entering and exiting this

room are rated at ¾-hour on both sides. This wall

is not properly constructed.



laboratory Sterilization room, above the door

going into the main area, the rated wall is not

complete to the overhead deck.



mechanical room, the steel support beams in the

mechanical space are not sprayed with

fireproofing as they have been throughout the

entire facility.



mechanical room there are 3 large penetrations

through the overhead deck to the floor above that

are not properly fire stopped. These penetrations

are filled with expandable foam in the void space

around the piping where it penetrates through the

sleeve. There are two ¾" conduits going through

one sleeve; there ' s another empty sleeve filled

the same way, and also a piece of 3-inch conduit

running up through another sleeve in the annular

space between the conduit and the sleeve.



mechanical room above the entrance door from

the corridor the fireproofing is missing in

several locations on the structural beams where it


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has been removed for the mechanical

hangers to be clamped onto it.


was observed that on the 1st floor, the

spray-on fireproofing in the Mechanical room is

not complete on the hanger clamps for

the mechanical equipment that has been

supported from the beams. Some of the spray-on

fireproofing has been scraped off in many areas.


was observed that on the 1st floor, in the

Secondary Mechanical room, there is a

core-drilled hole going through the overhead

rated concrete decking. It is approximately 1" in

diameter, open through the deck, with nothing

passing through it and no fire stopping.



Secondary Mechanical room most of the spray-on

fireproofing is not complete on the

bottom of the structural steel beams, and appears

to be the case throughout this room.


was observed that on the 10th floor, there are

unsealed penetrations in the fire hose cabinet.


was observed that on the 9th floor, elevator lobby

at speech therapy, above the drop ceiling, there is

combustible material (a plastic trash bag) that is

being used to strap cable.


was observed that on the 8th floor,

Manager, Nursing Support Services office, there


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is a damaged ceiling tile in place, at the

sprinkler head.



closet between the Assistant Administrator

Teletracking and the Manager, Nursing Support

Services, the ceiling tile in not in place.



corridor side of the transfer center, ceiling tiles

are not in place.


was observed that on the 8th floor, just

before you enter the Patient Transport area, there

is a closet with a fire alarm panel, the

ceiling tile has a hole, at the sprinkler head.



Outside the Director's office, there are 2 ceiling

tiles that are not in place.


was observed that on the 7th floor, data

closet across from room 760, in the ceiling, there

is a piece of electrical conduit without

any fire stop material installed.


was observed that on the 7th floor, near

the doors to the Mountain building, at the

expansion joint in the ceiling, there is a ceiling

tile that is not in place.




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outside of security office, near stairwell E8, inside

the telephone closet, there is a hole in

the finished ceiling.



closet across from the Preop Nurses Station,

ceiling tiles are not in place and there are holes in

the ceiling.



the Preop Nurses Station, above the drop ceiling,

there is sheet plastic material above the drop

ceiling.


was observed that on the 3rd floor, break

room to the rear of the receiving area, multiple

ceiling tiles are not in place.


was observed that on the 2nd floor,

telephone closet, near the Nuclear Medicine

waiting area, there are penetrations where

different types of sealants are overlapping each

other.



dumbwaiter, near the Nuclear Medicine waiting

area, there are multiple unsealed

penetrations.


was observed that on the 2nd floor, Safety

Service Office, there is a fire damper which needs

to be serviced.


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Service office, closet to the rear of the Police

Captain's office, there is no fire separation

between this area and the South building.


was observed that on the 3rd floor, break

room to the rear of the receiving area, there are

unsealed penetrations to the Boiler Room

below.


was observed that on the 1st floor, near

Conference Room C, where the escalator has

been abandoned, this area is being used for

storage, and is not properly enclosed and rated

and the wall at the bottom is not complete.


staff and patients in the smoke compartments

where they are located and any adjoining smoke

compartments.




Interior finish for rooms and spaces not used for

corridors or exitways, including exposed interior

surfaces of buildings such as fixed or movable

walls, partitions, columns, and ceilings, has a

flame spread rating of Class A or Class B. (In

fully sprinklered buildings, flame spread rating of

Class A, Class B, or Class C may be continued in

use within rooms separated in accordance with

19.3.6 from the access corridors.) 19.3.3.1,

19.3.3.2

K 015


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maintain the flame spread rating of the facility.

Findings Include:



telephone equipment closet in the large waiting

area has non-fire rated birch plywood

covering the walls for equipment mounting.


staff and patients in the smoke compartment

where they are located.




Corridors are separated from use areas by walls

constructed with at least ½ hour fire resistance

rating. In sprinklered buildings, partitions are only

required to resist the passage of smoke. In

non-sprinklered buildings, walls properly extend

above the ceiling. (Corridor walls may terminate

at the underside of ceilings where specifically

permitted by Code. Charting and clerical stations,

waiting areas, dining rooms, and activity spaces

may be open to the corridor under certain

conditions specified in the Code. Gift shops may

be separated from corridors by non-fire rated

walls if the gift shop is fully sprinklered.)

19.3.6.1, 19.3.6.2.1, 19.3.6.5

K 017


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Based on observations the facility failed to ensure

that corridors are separated from use areas.

Finding Include:


was observed that on the 9th Floor, above

the drop ceiling at the door to the Therapy office,

there are two penetrations of the corridor wall by

mechanical piping that are not properly fire

stopped.



Telephone Equipment room in the Staff Lounge

has multiple penetrations not properly fire

stopped.



Staff Breakroom has a 1/2-hour rated door frame

with a 20-minute rated door. This corridor wall

should be a 1-hour rated fire barrier but it is not

complete to the overhead decking and the door

and frame ratings do not meet the requirements

of an egress corridor


was observed that on the 8th Floor, in the small

office that the bathroom is being utilized as a

storage room.



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was observed that on the 8th Floor, in the

Telecommunications Closet in the small office

area that there are piping penetrations not

properly fire stopped. The fire caulking used is

two different colors and overlap each other.



2-hour fire barrier wall separating the East and

Mountain buildings was found to have a

penetration, approximately 3 ft above the drop

ceiling at the waiting area.



corridor near the vending machines was found to

have the drop ceiling being used as a

plenum. The corridors walls in this area are not

complete to the overhead deck. There are

multiple penetrations by electrical and heating

and cooling equipment and sections of the

wallboard are missing and not properly fire

stopped.


was observed that on the 8th Floor, above the

ceiling at the double doors in the separation wall

for the East and West buildings, it was

found there are 3 flex-conduits penetrating the

wall which are not properly fire stopped.



alcove at room 757 it was found the walls are not

complete to the overhead decking. This area

appears to be in a plenum ceiling.


was observed that on the 7th Floor,


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approximately 8" above the drop ceiling in the

corridor at room 757 there are two

penetrations not properly fire stopped. One is by

a 2 1/2" copper plumbing line and the

other is by a 1" hole. Both are near each other

approximately 30" above the ceiling.



approximately 2 ft above the drop ceiling at room

755 there is a penetration of the wall by a pipe

sleeve not properly fire stopped in the annular

space around the 2" steel plumbing line.



fire alarm panel room that there is a penetration

not properly fire stopped where the

sheetrock is cut out approximately 1 ft long by 3"

high and there appears to be only one

sheet of material on one side in that location.


was observed that on the 7th Floor, in the fire

alarm panel room that there is a penetration

through the wall by several lengths of

Romex style flexible conduit that is not properly

fire stopped.



alcove near room 752 above the drop ceiling it

was found there are two wall penetrations by 1"

sprinkler piping which is not properly fire stopped.



Biohazard Storage room approximately 6" above

the drop ceiling is a 1 1/4" sprinkler pipe


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penetrating the wall at the rear of the room which

is not properly fire stopped.



Biohazard Storage room that the wall is not

complete to the overhead decking to the left

above the door.



Biohazard Storage room that there are two

penetrations of the wall above the drop ceiling

by electrical conduit that are not properly fire

stopped and a section of the wall is not complete.



Soiled Holding room above the drop ceiling, has a

3/4 " conduit penetrating the wall without proper

fire stopping in the open end of the conduit.



former patient room at stairwell 3 that has been

converted to an office has 3 penetrations

through the wall above the drop ceiling at the door

by a plastic pipe, by a data cable and by

some black cabling. These penetrations are not

properly fire stopped and there also is a

section of the wall not complete to the overhead

decking above the bathroom area.



Mechanical room on the intermediate floor above

Floor 6 has a floor penetration by four

plumbing lines, 3" and 5" or 6" in diameter,

improperly fire stopped with expandable foam.


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large waiting room near the old information desk

across from the conference room, near

the Men's room above the ceiling in the corridor

the fire damper did not have proper angle

brackets at the wall and the area around the fire

damper penetration into the wall is not

properly fire stopped.



Biohazard room, none of the four walls are

complete above the ceiling to the overhead

decking. The old metal lathe and plaster ceiling

has big holes in it in many areas.



Laboratory area at Stair #5 the rated wall was

found to have several penetrations not

properly fire stopped. One hole is by a 3/4"

electrical conduit, one is by a 3 or 4" plastic

sprinkler pipe, another is by a piece of kindorf

strut, another is by a 1/2" electrical Romex

flexible conduit. These are approximately 6"

above the drop ceilings.


was observed that the 6th Floor

Laboratory office wall there are two plumbing

lines penetrating the wall which are not




Water Filtration area behind Dialysis is indicated

as having 2-hour rated separation walls.


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It was found above the drop ceiling in the corridor,

near stair 5 that there is a bank of four or

five electrical conduits penetrating through the

wall and not properly fire stopped. It also

was found that several data cables are also

penetrating the corridor wall above the drop

ceiling at the room door.



Mechanical Room by stair 5 has two floor

penetrations under panel 5MC that are not

properly fire stopped. One has an open sleeve

that has pink glass wool insulation stuffed

into it, and the other has a piece of three-inch

conduit running up through it and the sleeve

is filled with expandable foam. These are not




small Mechanical Room near stair #5 has a 1"

drain line for the sprinkler system

penetrating the Mechanical Room wall and not

properly fire stopped in the annular space.



outside of the Dialysis area in the telephone

equipment room there are penetrations sealed

with 2 or 3 different kinds of fire-rated caulking

overlapping each other in 2 locations with

data cable running through pneumatic tubing.



Mechanical room has two ¾" electrical conduit

penetrations through the block wall not far

from where that electrical box is not covered.


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Environmental Services corridor into the waiting

room, near the Information Desk, at the

smoke wall above the double doors has two

different types of fire caulking overlapping each

other.



telephone equipment room, near the dumbwaiter

shaft, there are several locations where

fire stop caulking has been used with two or three

brands and types all overlapping each



mechanical room, at the stairwell #5 wall, the

steel beam, where it intersects with the wall

above the brick column, does not appear to be




mechanical room by stair #5, a plumbing line near

the back window of the room is

penetrating above the overhead deck that has

been fire stopped with two types of fire-rated

caulking overlapping each other.



two-hour rated wall above the double doors at the

entrance to the Blood Bank area has a

penetration by a couple dozen data cables, all in

a bunch. This penetration is not properly

sealed with fire stopping.


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Blood Bank corridor wall above the fire shutter

and the drop ceiling has multiple

penetrations from mechanical piping, electrical

conduit, data cabling, etc. This wall is not

complete to the overhead deck. This wall does

not appear to be of rated construction.



Blood Bank near the break room/fax room area

has 2 penetrations through the corridor

wall 3 or 4 inches above the drop ceiling by data

cable through approximately two 1" holes

without proper fire stopping.



Blood Bank back wall in the break room area has

a large hole, about 3' x 3', up through the metal

lathe and plaster ceiling, in the corner near the

office. The wall between the two

laboratories should be a rated wall and the ceiling

should prevent the passage of smoke.



Blood Bank area in the back rear corner small

office has the wall construction that does not

appear to be rated above the laboratory door.

Also a 3" hole penetration through the

metal lathe and plaster wall was found with 2 data

cables running through it approximately a foot

above the drop ceiling.


was observed that on the 3rd floor, above

the ceiling in the Blood Bank laboratory at the rear


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emergency exit is a 2-hour rated wall

not properly constructed. There appears to be

acoustic ceiling tile covering what is a large

through penetration. This is located over the exit

door. There is a second penetration about 6-8

feet away with data cable running through a 1"

hole through the metal lathe and plaster.



egress corridor walls at the elevator lobby are not

complete to the overhead decking above

the Z-spline ceiling. This was found at elevators

1 and 2 east.



Environmental Services area above the drop

ceiling has the remnants of the old Z-spline

ceiling with many penetrations and holes in it.

The new drop ceiling appears to be used as a

plenum. The walls above the drop ceiling do not

appear to be complete to the

overhead deck and the old Z-spline ceiling has

holes in it that are allowing air to free flow

in the interstitial space above it.



Mechanical room (entrance from the courtyard)

has one penetration by two ¾" electrical

conduits up through the overhead deck which are

not properly sealed around the annular

space between the walls of the conduit and the

hole in the decking with fire stopping.



Secondary Mechanical room, above a large


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section of duct, the rated wall that attaches to

the back of the first-floor offices has an extremely

large hole in the metal lathe and plaster,

approximately 12" x 12" in size, with no

mechanical or electrical equipment going through

it. This hole is not properly sealed with fire

stopping.



Secondary Mechanical room, right of the entry

door is a large penetration by a six-inch

sprinkler standpipe water main. It appears this

main is entering through the common wall

from the main building and is not properly fire

stopped. The penetration is approximately

1 ½ ft by 8 to 10 inch wide hole through the

concrete block wall that is not properly fire

stopped.


was observed that on the 9th floor, Rehab

area, there are unsealed penetration in the

finished ceiling at the sprinkler piping and the air

duct.



outside of the Clinical Resource Nurses office,

there is a unsealed penetration of the

corridor wall, between the floor and the guard rail.



the drop ceiling, across from Stairwell E8, next to

the elevator shaft, there is an unsealed

penetration of the wall by a network cable bundle.



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Preop PACU ASU Preceptor ' s office, in the

closet, there is a unsealed penetration of the

wall near the sprinkler escutcheon.




compartments.




Doors protecting corridor openings in other than

required enclosures of vertical openings, exits, or

hazardous areas are substantial doors, such as

those constructed of 1¾ inch solid-bonded core

wood, or capable of resisting fire for at least 20

minutes. Doors in sprinklered buildings are only

required to resist the passage of smoke. There is

no impediment to the closing of the doors. Doors

are provided with a means suitable for keeping

the door closed. Dutch doors meeting 19.3.6.3.6

are permitted. 19.3.6.3

Roller latches are prohibited by CMS regulations

in all health care facilities.


K 018



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ensure that doors protecting corridor openings

are maintained as required.

Findings include:


was observed that on the 9th Floor, for

the Director of Medical/Surgical Services office

that the door has a roller latch on it going

into the emergency egress corridor.


was observed that on the 8th Floor,

Alexander Levitov, M.D., Medical Director's office

had a roller latch on the door.



former patient room at stairwell 3 has been

converted to an office and has a roller latch on

the door.



Blood Bank has a fire shutter in the corridor wall

opening with a fusible link that is dated

1993 and does not appear to have had the

required periodic servicing and testing. The

drop-down shutter was found to have items sitting

on the shelf underneath it so it may not

close completely when activated.



Rear Emergency Exit door for the Blood Bank

laboratory has a label on the door that appears to

indicate that it ' s a 1 ½ hour rated door. The

construction of this door seems to be a hollow

Luan laminated wood door. It is suspected that


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the door rating and the hardware are not properly

fire rated and it does not have a closer. This door

is the exit from the lab to the rear corridor.



rated entry door into the Blood Bank area does

not have rated hardware on the door and

has several metal patches over holes in the door,

which may compromise the rating of the door


was observed that on the 1st floor, near

elevators 1 and 2 at stair E4, the double doors

going into the administrative office area from the

corridor are not labeled rated doors. They also do

not have closers on them or fire rated hardware.


was observed that on the 8th floor, Dr.

James Franko, Hospitalist's Director's office, that

the door will not latch. There is a roller latch on

the door.


was observed that on the 3rd floor,

courtyard loading dock, the double doors to the

building will not close and latch. The doors

have been damaged.



Radiology, Treadmill room 3, the corridor door will

not close and latch.


was observed that on the 2nd floor

Radiology Scan room 5, the door will not close

and latch.


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This has the potential to affect all staff and

patients, on the affected floors.




Stairways, elevator shafts, light and ventilation

shafts, chutes, and other vertical openings

between floors are enclosed with construction

having a fire resistance rating of at least one

hour. An atrium may be used in accordance with

8.2.5.6. 19.3.1.1.


K 020


ensure that the fire resistance rating of stairways

and shafts was maintained.

Findings include:


was observed that on the 9th Floor, in the Staff

Lounge, the former dumbwaiter shaft is now

being used as the vertical shaft for the

pneumatic delivery system piping. This shaft was

found to have multiple holes and major

penetrations without proper fire stopping and

proper construction.


was observed that on the 8th Floor, that

the old Dumbwaiter shaft which is being utilized

as a vertical mechanical shaft for the

pneumatic delivery system, has multiple

penetrations and sections of the CMU block


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missing from the walls of the shaft. The

penetrations are not properly fire stopped and the

walls are not complete.


was observed that on the left side of the

elevator shaft as you're facing the doors, on the

5th floor, there are 2 holes in the block wall next

to an electrical junction box, which are not



was observed that on the top of the

elevator shaft, one corner has a penetration that

is not properly fire stopped and two big

sections of block with a plaster coating which also

need to be properly fire stopped. There

are 3 penetrations across the front of the shaft at

the top that need to be fire stopped as well.

Underneath the concrete beam, on the right side

as you ' re looking in the shaft from the doorway,

at the top of the block, there is no fire stopping.


was observed that on the 8th floor in the

elevator shaft, above the doors, the concrete

beam where the top course of block meets the

beam is not grouted, and also the left corner as

you're facing out the doors has a large section of

block missing.


was observed that on the elevator shaft,

the concrete block mortar is not complete where

the concrete beams are embedded in the

elevator shaft walls. This appears to be the case

the entire length of the shaft.



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was observed that on the corner joint left

side of the elevator shaft sections of the block are

missing. The tops of the doors are not properly

fire stopped where the frames meet the block.

This appears to be the case for the entire shaft.


was observed that on the East elevator

shaft, a concrete beam at the top of the shaft, just

above the door on the right side of the

shaft as you're looking out of the elevator doors,

needs to have the mortar repaired in the

top course of block underneath the concrete

beam in the sidewall.


was observed that on the top of the North

elevator shaft, there are several pieces of conduit

and static cable penetrating the shaft



was observed that on the 8th floor level,

behind the door, angle iron needs to have proper

draft stopping in the North elevator shaft. There

also appears to be a penetration by another

conduit through the shaft wall at the

bottom without being properly fire stopped. A

small amount of combustible debris was

found in the bottom of the shaft.


was observed that on the 8th floor, in the front of

the North elevator shaft, the corner behind the

door channel it is not properly fire stopped.


was observed that on the 7th Floor, in the Staff

Breakroom telephone equipment closet that the


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mechanical shaft has an access door

that is not a rated door and is not properly closing

and latching.



Telephone equipment room near the old

dumbwaiter shaft that the penetrations into the

shaft were improperly fire stopped with two types

of fire rated caulking overlapping each

other. These were approximately 2 ft off the floor.


was observed that on the 5th floor, it was

found in the Water Purification room behind

Dialysis that the wall is not complete to the

overhead decking above the room door. The drop

ceiling grid in that room continues above

the wall, through and into, the exit corridor for

stair 5.



Mechanical Room by stair #5 has three ¾" open

ended electrical conduits penetrating the

overhead rated floor and they are not properly fire

stopped in the ends.



Mechanical Room by stair #5 there is a

penetration through the overhead decking not

properly fire stopped around what appears to be a

4- or 5-inch copper plumbing pipe in the

corner of the room.


was observed that on the 5th floor stairwell #5

Mechanical shaft , between 5th and 4th floors at


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the intermediate landing, multiple penetrations

through the side wall of the shaft are not properly

fire stopped. There are three 3" electrical conduits

and two ¾" conduits as well as data cable, along

with several plumbing lines and some other wires

going through two different large penetrations.


was observed that on the 5th floor Stair

#5 has a rated Mechanical chase in the back of

the stairwell. It penetrates each floor as it

extends upward. The existing fire stopping is not

complete from the top and bottom of the

penetration.



mechanical room, above the entrance door from

the corridor, core-drilled hole containing a piece

of 3/4" conduit penetrates the floor above into the

mechanical space that is not properly fire

stopped.


was observed that on the 8th floor corridor side of

stairwell E8, there is an unsealed penetration of

the cinder block wall by an electrical conduit.


was observed that on the 6th floor, next to the

Non-invasive Manager for Echo and EKG, there

is a dumbwaiter shaft which is no longer used for

the dumbwaiter.. Ductwork and network cables

have been installed in the shaft and run vertically

in the building.



outside of the Electrophysiology Lab, at the


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dumbwaiter shaft, there is a penetration of the

shaft. There is also an access hatch in this area,

which does not appear to be correctly enclosed.



closet on left side, end of corridor from Preop

Nurses station, the vertical shaft is not enclosed,

going upward.


patients in the building.

The above was witnessed by Maintenance

Department personnel.


Any door in an exit passageway, stairway

enclosure, horizontal exit, smoke barrier or

hazardous area enclosure is held open only by

devices arranged to automatically close all such

doors by zone or throughout the facility upon

activation of:

a) the required manual fire alarm system;

b) local smoke detectors designed to detect

smoke passing through the opening or a required

smoke detection system; and

c) the automatic sprinkler system, if installed.

19.2.2.2.6, 7.2.1.8.2


K 021


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ensure that doors to hazardous area enclosures

were automatically closing.

Findings include:


was observed that on the 5th floor, it is

shown on the plans that a 2-hour separation wall

exists between the West main elevator

lobby and the Chaplain ' s office area, separating

the East and the West buildings. Upon

investigation it appears the two-hour rated wall

does not have rated doors in it. The existing

double doors are not labeled as being rated. They

do not have automatic closers and they remain

open all the time without automatic releases.



storage room in the Dialysis area has a one-hour

rated door with a magnetic holder on it.

A cart was found obstructing the door from

closing.



Dialysis area at the rated double doors in the

corridor near the dumbwaiter area, the two doors

do not properly close. There is an existing door

edge astragal on one leaf of the door that

prevents the doors from closing in proper

sequence.



Endoscopy Storage room the ¾-hour door with

the closer was tied in the open position.


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was observed that on the 2nd floor, the

fire doors separating the East building and the

South building, did not close during operation

of the fire alarm system..

This has the potential to affect all patients and

staff in the smoke compartment.




Access to exits is marked by approved, readily

visible signs in all cases where the exit or way to

reach exit is not readily apparent to the

occupants. 7.10.1.4


K 022


ensure that exit signs are visible.

Findings include:



Blood Bank rear corridor is shown as an exit route

on the fire escape plan on the wall, and

indicates the route to be through two sets of

double doors to the main exit corridor but


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there is no exit sign.



horizontal exit to Mountain, the exit sign is

obstructed where it makes the L into the

corridor going into Mountain. It is not visible as

you look down the corridor.



looking down the corridor from Echovascular

Exam 4 to the stairway, the exit sign is not visible.


was observed that on the 3rd floor, just

outside of mail clerk's room, the signage for

egress from this area is not properly identified.






Smoke barriers are constructed to provide at

least a one half hour fire resistance rating in

accordance with 8.3. Smoke barriers may

terminate at an atrium wall. Windows are

protected by fire-rated glazing or by wired glass

panels and steel frames. A minimum of two

separate compartments are provided on each

floor. Dampers are not required in duct

penetrations of smoke barriers in fully ducted

heating, ventilating, and air conditioning systems.

19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4

K 025


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maintain the smoke barriers.

Findings include:


was observed that on the 6th Floor, in the PST

corridor, the exterior corridor does not have a

smoke barrier separation between the

North and East buildings as was shown on the

fire plan. The existing wall does not have

smoke-tight doors on it to provide the required

separation.


was observed that on the 3rd floor, outside of the

electrical/telephone equipment interface closet in

the corridor above the double doors is one

penetration by a wire through a 1" hole through

the metal lath and plaster


was observed that on the 3rd floor, is one

2" hole penetration by a large data cable through

the rated corridor wall which is not

properly fire stopped. This was witnessed across

from the electrical closet at the double

doors, approximately three feet away from the

break room door and about 6" above the

drop ceiling.



restricted area doors, above the smoke partition

doors going into the Patient Rehab area,

there is a identified smoke partition wall where the


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penetration sealant material has fallen

off the penetration.



security office, above the drop ceiling at the

entrance door, there are unsealed penetrations.

There are also penetrations in this same area that

have different types of material, contacting each

other.

These have the potential to affect all staff and

patients in the smoke compartment where the

violation occurs and the adjoining smoke

compartment.




Door openings in smoke barriers have at least a

20-minute fire protection rating or are at least

1¾-inch thick solid bonded wood core. Non-rated

protective plates that do not exceed 48 inches

from the bottom of the door are permitted.

Horizontal sliding doors comply with 7.2.1.14.

Doors are self-closing or automatic closing in

accordance with 19.2.2.2.6. Swinging doors are

not required to swing with egress and positive

latching is not required. 19.3.7.5, 19.3.7.6,

19.3.7.7


K 027


ensure that door openings in smoke barriers were

maintained.


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Findings include:


was observed that on the 7th Floor, in the Soiled

Holding room the door closer was not closing the

door completely and latching it.



Dialysis area the storage room door does not

close completely.


was observed that on the 5th floor, the 1 hour

rated door to the Water Purification room behind

Dialysis is not properly latching.



Environmental Services rated door is not closing

and latching.



Environmental Services area has the drop ceiling

being used as a return air plenum. Above

the ceiling in one of the back offices is a 3 ½ to 4

ft x 2 ½ to 3 ft hole up through the metal lathe and

plaster ceiling above the drop ceiling.



stairwell 4E, the smoke doors have an excessive

gap between the doors.


was observed that on the 3rd floor, just outside of

mail clerk's room, the gap at the rated fire doors

is excessive.


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patients in both smoke compartments.




One hour fire rated construction (with ¾ hour

fire-rated doors) or an approved automatic fire

extinguishing system in accordance with 8.4.1

and/or 19.3.5.4 protects hazardous areas. When

the approved automatic fire extinguishing system

option is used, the areas are separated from

other spaces by smoke resisting partitions and

doors. Doors are self-closing and non-rated or

field-applied protective plates that do not exceed

48 inches from the bottom of the door are

permitted. 19.3.2.1


K 029


maintain construction for hazardous areas.

Findings include:



Janitor's closet door does not completely close

and latch.



Physical Therapy office it was found that the room

being used as a storage room was in fact a

breakroom before and the construction does not


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appear to meet the requirements for a

combustible materials storage room.


was observed that on the 7th Floor, inside

room 756 bathroom it was found that the

bathroom has been converted into an office

supply storage room with combustible materials

being stored. The door to this room did not have

a door closer.



Room 752 bathroom contains wooden pallets and

trash in cardboard boxes on the pallets.

This appears to be a combustible trash storage

room now.


was observed that on the 7th Floor, Soiled

Holding room, the corridor wall above the drop

ceiling at the door was not complete to the

overhead deck.


was observed that on the 7th Floor, half

of the former patient rooms down the corridor on

this floor have already been, or are currently

being converted from patient rooms to

laboratories. This constitutes a change of

use for these rooms.



Biohazard room that the doors are not rated

doors with fire rated hardware and frames.




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Laboratory door near Stair #5 is not a rated door.



Dialysis Soiled Utility room does not have a closer

on the door.



Laundry room, the room construction did not

appear to be properly rated. There is no

rated door, no closer, no rated door frame, and

the walls appear not to be of rated construction.



Surgical Pathology lab does not appear to be of

properly rated construction. There is no

rated door, no rated door frame and no closer on

the door.


was observed that on the 3rd floor, cage

area of receiving. The rated door to the storage

area was propped open.

The above have the potential to affect all staff and

patients in the smoke compartment where they

are located.




Exit access is arranged so that exits are readily

accessible at all times in accordance with section

7.1. 19.2.1

K 038


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maintain the exit access so that it is readily

accessible.

Findings Include:



Mini Distribution area has an exit vestibule that

goes into the corridor and carts are stored on

either side of the walls.


was observed that on the 1st floor exterior egress

from the stairwell at the Executive area, the path

of egress from the building to the street is

incomplete.


patients in the building..




Width of aisles or corridors (clear and

unobstructed) serving as exit access is at least 4

feet. 19.2.3.3


K 039


maintain the aisles or corridors serving as exit

access to at least 4 feet in width.


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Findings Include:



large waiting area, stair #4 the exit was blocked

with furniture. The exit access has been

reduced to approximately 36".


patients in the affected compartment of the

building..




Exit and directional signs are displayed in

accordance with section 7.10 with continuous

illumination also served by the emergency lighting

system. 19.2.10.1


K 047


display exit signs as required by the Life Safety

Code.

Findings Include:



Environmental Services exit sign into the corridor,

does not appear to be illuminated.


patients in the affected area of the building..


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There is a written plan for the protection of all

patients and for their evacuation in the event of

an emergency. 19.7.1.1


K 048


maintain a written plan of protection for the

evacuation of patients in an emergency.

Findings Include:


was observed during facility record review,

the facility failed to maintain written emergency

procedures manuals at the nurses stations

to be available to facility staff members.






Fire drills are held at unexpected times under

varying conditions, at least quarterly on each shift.

The staff is familiar with procedures and is aware

that drills are part of established routine.

Responsibility for planning and conducting drills is

assigned only to competent persons who are

qualified to exercise leadership. Where drills are

conducted between 9 PM and 6 AM a coded

K 050


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announcement may be used instead of audible

alarms. 19.7.1.2


Based on records provided by Carilion, the facility

failed to conduct fire drills and maintain records in

accordance with guidelines in NFPA 101.

Findings include:


was observed that on the facility records

the fire drills are not being conducted with proper

frequency and properly documented.



the periodic service, inspection and testing of the

fire alarm system is not being completed.






All required smoke detectors, including those

activating door hold-open devices, are approved,

maintained, inspected and tested in accordance

with the manufacturer's specifications. 9.6.1.3


K 054

Based on observations and review of records, the

facility failed to maintain, inspect, and test the


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



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buildings smoke detectors.

Findings include:


was observed that on the facility records it

appears the smoke detectors have not had the

required sensitivity testing conducted.



Laundry room, in the back corner is a smoke

detector with tape covering it.



The above was confirmed by Maintenance



If there is an automatic sprinkler system, it is

installed in accordance with NFPA 13, Standard

for the Installation of Sprinkler Systems, to

provide complete coverage for all portions of the

building. The system is properly maintained in

accordance with NFPA 25, Standard for the

Inspection, Testing, and Maintenance of

Water-Based Fire Protection Systems. It is fully

supervised. There is a reliable, adequate water

supply for the system. Required sprinkler

systems are equipped with water flow and tamper

switches, which are electrically connected to the

building fire alarm system. 19.3.5


K 056


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

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ensure that the building fire sprinkler equipment

was maintained in accordance with NFPA 13 and

25.

Findings include:



stairwell #4, the sprinkler control, test and drain

valves are not marked with proper signage.



Rehabilitation back office that the partial-height

partition wall does not continue to the ceiling and

has sprinkler piping, not properly supported and

laying in the top of the lighting tray.



Stairwell #7, the sprinkler drain valve does not

have proper signage.



sprinkler equipment does not have signs

indicating which area of the building or system

they control.


was observed that on the 6th Floor, there

is no sprinkler protection at the top of the stairwell

in Stair #9.


was observed that on the 6th Floor, in the PST

room that there is no sprinkler protection in the

main room or the patient bathroom.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

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DEFICIENCY)

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Stairwell #5 that the sprinkler control and test

valves do not have proper signage.


was observed that on the 5th floor, there

is no sprinkler protection in the area near the

Chaplain's corridor, the Employee Lounge area,

or over by the old dumbwaiter.



Mechanical Room by stair #5 there is a 3"

sprinkler line with a low-point drain on it. There is

no signage on the drain valve to indicate what it is

for.



Mechanical Room by stair #5 there are 2 sprinkler

drain valves that do not have proper signage.


was observed that on the 5th floor, stair

#5 Sprinkler sectional control, test, and drain

valves don't have proper signage.


was observed that on the 7th floor, in

stair #5 the sprinkler control valve doesn't have

proper signage.


was observed that on the 3rd floor, there

is no sprinkler protection in this area.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






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Mechanical room by the courtyard area has a

sprinkler auxiliary drain that does not have

any signage on it indicating its purpose.




door is a Fire Department hose cabinet with

a 2 ½-inch hose valve inside which is not marked

with proper signage as a Fire Department

Hose Valve.


was observed that on the 1st floor East Building

there is no sprinkler protection throughout the

entire area.


was observed that on the 7th floor, Clean

Equipment storage room across from the nurses

station, there is no sprinkler coverage.


was observed that on the 6th floor, corridor to

crossover to medical building, there is no

sprinkler coverage.


was observed that on the 3rd floor, exterior of the

building, courtyard loading dock, there is an

overhang without proper sprinkler coverage.


was observed that on the 2nd floor, outside of the

Nuclear Medicine waiting area, there is a dirty

linen room with no sprinkler coverage.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

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Service office, storage room, immediately to the

left when you enter, there is no sprinkler

coverage in this room.



Service office, closet to the rear of the Police

Captain's office, there is no sprinkler coverage in

this area.


was observed that on the 2nd floor, safety

service office, in the room behind the electrical

panel, there is fire protection equipment

that does not have the proper signage.


was observed that on the 2nd floor, employee

break room, the room does not have sprinkler

coverage.


was observed that on the 1st floor,

Conference Room C, Administration, there is a

closet with no sprinkler coverage.


was observed that on the 1st floor, Vice

President Suite area, there is sprinkler coverage

in some offices, and none in others.

This has the potential to affect the entire building.




Required automatic sprinkler systems are

K 062


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



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continuously maintained in reliable operating

condition and are inspected and tested

periodically. 19.7.6, 4.6.12, NFPA 13, NFPA

25, 9.7.5



maintain the automatic sprinkler system.

Findings include:



the Mechanical room that the sprinkler system

inspector's test connection is missing the

required smooth bore orifice in the discharge

outlet.



Janitor's closet that the sprinkler appears to be

corroded and may need to be replaced.


was observed that on the 6th Floor, a sprinkler

was found that appears to be obstructed by a

surface-mounted light fixture at the

separation wall between the East & West Towers.



intermediate level Mechanical room above the 6th

floor has a sprinkler system inspector's

test valve without proper signage.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

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the sprinkler systems have not had the required

five year service conducted.


was observed that on the facility records the

standpipe systems have not had the required

periodic service and flow testing conducted.



Dialysis Room there was one damaged sprinkler

deflector as you enter the area from the

storage room into the Dialysis area.



Water Purification room behind Dialysis has two

sprinkler heads missing the escutcheon trim

rings.



Mechanical room at stair #5 has a sprinkler under

a duct with the deflector pushed up into

the ductwork insulation. It needs at least a

one-inch gap between the deflector and the

overhead.



Pediatric clinic area rest room has a sprinkler that

has been painted, and it is also missing a

trim ring for the escutcheon.



waiting room area near the telephone alcove area

that one sprinkler is missing the escutcheon trim

ring.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

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Endoscopy area, at the double fire doors, near

the entrance, a sprinkler is recessed into the

ceiling too far, which may present an obstruction

to the spray pattern, and the trim ring is

missing near the exit sign.



Endoscopy Procedure Room #1 has two

sprinklers in the ceiling that have been painted.

These also do not have proper escutcheon trim

rings. The plates that are in place do not

appear to be installed correctly and may be glued

to the ceiling.



Endoscopy Storage room the two sprinklers, of

the two in the room, have concealed type

plates incorrectly installed. There is no cup to

hold them in place. They appear to be affixed to

the speaker deflector in some manner.



Endoscopy area in the corridors and outside of

the Nurses ' Station has concealed type

covers on the sprinkler heads for the recessed

sprinklers in the ceiling that may not be listed for

use as they are installed. Confirmation is needed

that these escutcheons are listed for use with the

Viking Model M sprinklers.



Endoscopy break room, the two sprinklers are


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

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missing the concealed type plates and/or

proper escutcheon trim rings.




door, is a Fire Department hose cabinet with a

mechanical pipe running in front of it which

appears to obstruct access to it. It is

questionable as to any past service conducted on

this valve given its location and apparent

condition.



area, that sprinkler piping in this area is not

properly supported and secured.


was observed that on the 8th floor, patient

transfer office, sprinkler escutcheons are pulled

down, obstructing the sprinkler


was observed that on the 5th floor, security office,

at the closet, near the break room, there is a

pre-action sprinkler system located in the closet,

with no signage.



there is a pull station for the pre-action system,

without correct signage.



captains office, there is a sprinkler head with a

missing escutcheon.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

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DATE

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was observed that on the 5th floor, just outside of

security office, near stairwell E8, inside the

telephone closet, there is a sprinkler head

missing an escutcheon.


was observed that on the 4th floor, corridor to the

rear of outpatient recovery, just outside the staff

lounge room, the sprinkler head deflector is

contacting the escutcheon.


was observed that on the 3rd floor, medical gas

storage room, located off of the loading dock,

there is a dry pipe system that is not accessible, it

is blocked by storage.


was observed that on the 3rd floor, loading dock,

exterior of building, there is piping which is

believed to be a drum drip for the sprinkler

system, without proper signage.


was observed that on the 3rd floor, stairwell 4E,

there is a fire department, main control valve, and

a test valve, without proper signage.


was observed that on the 2nd floor, outside of

Imaging PAC Support, there are escutcheons

missing from the sprinkler heads.






A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

ID

PREFIX

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Portable fire extinguishers are provided in all

health care occupancies in accordance with

9.7.4.1. 19.3.5.6, NFPA 10


K 064


provide portable fire extinguishers as required.

Findings Include:


was observed that on the 5th floor, the exit

corridor to stairwell 5 has a Carbon Dioxide BC

style fire extinguisher.


was observed that on the 10th floor, outside of 4

east stairwell, the fire extinguisher located in this

area is a Carbon Dioxide Extinguisher. This is

the improper type of fire extinguisher for the

hazard.


was observed that on the 1st floor, behind

Conference Room C, in the vestibule, there is a

CO2 fire extinguisher installed. This is not the

proper extinguisher for the hazard.


patients in affected area..



K 067 NFPA 101 LIFE SAFETY CODE STANDARD K 067


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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Heating, ventilating, and air conditioning comply

with the provisions of section 9.2 and are installed

in accordance with the manufacturer's

specifications. 19.5.2.1, 9.2, NFPA 90A,

19.5.2.2


Based on observations, the facility failed to install

equipment in accordance with manufacturers

specifications.

Findings Include:


was observed that on the 6th Floor , the

large waiting room near the old information desk

across from the conference room near the Men's

room above the ceiling in the corridor, a fire

damper was closed. This appears to be

a fire damper but is placed in a smoke barrier

wall.



the fire and smoke dampers have not had the

periodic service and testing and inspections

conducted.



Dialysis area has a little computer work station in

the back and the existing fire shutter

mechanical link is dated 2001. It ' s unknown if

this shutter has been properly tested and/or

serviced in the last five years.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






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found in the Endoscopy Storage room, above the

ceiling to the left there is a wall fire

damper. It appears that the fusible link has been

oversprayed with paint.



Laundry room, the dryer ducting appears to be

discharging back into the room and is not

properly vented to the exterior of the building.



Biohazard Storage room that the ceiling is being

utilized as a return air plenum and there

was found a fire damper through one of the walls

above the ceiling. It is not known if this

fire damper has been serviced and/or tested as

required. Section 19.3.6.4.



area, the HVAC flexible air duct is pulling loose

from the diffuser.






No furnishings or decorations of highly flammable

character are used. 19.7.5.2, 19.7.5.3, 19.7.5.4

K 073


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

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Based on observations, the facility allowed the

use of furnishings and decorations of a highly

flammable character.

Findings Include:



Staffing Resource Pool Office had a combustible

vine wreath decoration on the door.


was observed that on the 8th Floor, in the Faculty

of Medicine Hospitalist Services that the entry

door was completely encased in wrapping paper

and a bow.



are located.




Piped in medical gas systems comply with NFPA

99, Chapter 4.


K 077


ensure that piped in medical gas system was

installed properly.

Findings include:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






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was observed that on the facility medical gas

system, the piping is not properly marked through

out the facility as required.






Interior walls and partitions in buildings of Type I

or Type II construction are noncombustible or

limited-combustible materials. 19.1.6.3


K 103


ensure that interior walls and partitions are

noncombustible or limited-combustible materials.

Findings Include:



outside of the Clean Utility room was found a sign

hung from the drop ceiling and supported with a

wood plank installed in the unsprinklered area



patients in the compartment where the material is

located.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

ID

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K 130 NFPA 101 MISCELLANEOUS

OTHER LSC DEFICIENCY NOT ON 2786


K 130


ensure that systems are maintained as required.

Findings Include:



Secondary Mechanical room, the sprinkler

standpipe feed main piping has a drain valve on

it with no plug in the valve and it also does not

have proper signage, as required by 2000 NFPA

14, 11-1 and NFPA 13.


was observed that throughout the East building,

the fire department standpipe connections in this

building lack a male fitting for the fire department

to connect a hose and there are no caps on any

of these connections, as required by 2000 NFPA

14, 2-7





Electrical wiring and equipment is in accordance

with NFPA 70, National Electrical Code. 9.1.2


K 147


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

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ensure that electrical wiring was in accordance

with NFPA 70.

Findings Include:



the Storage room that a fire alarm panel is

mounted inside. This room is across from the

Care Management office, there is an electrical

junction box above the drop ceiling with several

knock-outs missing.



the Mechanical room on the roof that there is an

electrical junction box missing a cover.



Rehabilitation back office that a floor electrical

outlet does not have a cover on it.



Staffing Resource Pool Office had two portable

power strips plugged into each other (daisy-

chained) instead of plugged directly into a wall

outlet.



room 865, on the right side at the corridor wall

door that an electrical outlet cover is broken.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






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room 864 there are two power strips daisy

chained together.



double corridor smoke doors had the electrical

door holder missing the cover with exposed

wiring. This is near the Faculty of Medicine

Hospitalist Services office.


was observed that on the 8th Floor -

Room 862 has daisy chained power strips. An

extension cord is plugged into one power

strip and is being utilized as permanent wiring.

The extension cord is running through a

desk support, and supplies power to a

refrigerator.



room 752 that a refrigerator is being powered by

an extension cord being utilized as

permanent wiring which is running up the wall and

over a doorway


was observed that on the 7th Floor, in room 752,

the room has been set up to accommodate a

temporary laboratory and there are two large

electrical power cords passing down through the

drop ceiling on either side of the room.



"Stat Room" 758 and also room 751 appear to be

converted patient sleeping rooms that are now

being used as Laboratories. There are two large

flexible power cords dropping down through the


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






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drop ceilings on either side in both rooms to

power the equipment now in the rooms.



"Stat Room" 758 bathroom is now being utilized

as a water filtration equipment room and

the equipment is being powered by three different

extension cords.



Soiled Holding room that the light switch has

been broken off the wall. The switch is still

in place but can no longer be used to turn on the

light in the room.



small office outside of stairwell #3 has a surge

suppressor style portable power tap device.

This is a non-approved power tap.



Biohazard room there are two electrical junction

boxes above the drop ceiling missing covers.



Storage Room above the drop ceiling are two

electrical boxes missing covers; one over the

door and one back about four tiles away from the

door.



Mechanical Room by stair #5 that a very large

wiring junction box has the cover missing.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






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Mechanical Room by stair #5 that there is a

second large junction box with a knockout

missing in the side.



Mini Distribution area has daisy-chained power

strips powering a computer back in the left



Mechanical room has an electrical box missing a

cover up on the wall.



Endoscopy Storage room, above the drop ceiling,

at the entry door, there is one electrical junction

box missing a knockout. Also, to the right side,

through a fire damper in the wall,

appears to be household wiring that is spliced

together with no junction box and the wiring

is running through the wall above the damper

sleeve.


was observed that on the 4th floor, at stair 5,

there is a knockout missing on an electrical

junction box.



electrical mechanical room a ladder was stored in

front of electrical panel 4CX.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






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Blood Bank area small office in the back has 2

power strips daisy-chained together under

the desk.



Blood Bank area, rear laboratory, in the left-hand

corner has 2 daisy-chained power strips.

These are being used as permanent wiring for

some of the lab equipment.



the ceiling by the rear exit door of the Blood Bank,

is an electrical wiring junction box missing a cover

with wires hanging out of it.



Environmental Services area has a large

equipment storage room. There is equipment

being stored in front of an electrical panel..



Secondary Mechanical room, left of the door as

you enter, and above the steam tunnel,

there is an electrical wiring junction box missing

the cover and the wiring is exposed.



Secondary Mechanical room, Panel IAX is

missing the interior cover exposing the wiring

inside the panel at the breakers. Below that panel

is also a specialty outlet in a back box

which is missing the cover plate.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






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Secondary Mechanical room is a bus-duct

underneath the bank of electrical panels which

has an electrical knockout missing.



Secondary Mechanical room, is a wiring junction

box, approximately 18" x 18" that has

the cover missing off of it near where the large

core-drilled hole was found.



Secondary Mechanical room is a junction box that

has an electrical light fixture hanging out

of it by its wires. There is no cover and it is

unknown if there is any power going to it.



Secondary Mechanical room, to the right of the

door at the overhead deck is a liquid-tight

conduit with wire hanging out and not terminated

in a junction box.



Shenandoah Life Insurance Company dedicated

office has what appears to be a non-

approved surge suppressor type multi-plug

adapter instead of a resettable breaker-type

power tap.



Nursing Administration office has two

daisy-chained power strips under the desks.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

03 - EAST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






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was observed that on the 6th floor -

Echovascular Transcription, back cubicle, there

are power strips which are not plugged

directly into a wall outlet.


was observed that on the 2nd floor, old

north boiler room, there is a large electrical

junction box, the cover is not in place.

These have the potential to affect the smoke

compartments where they are located.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

1A - SOUTH TOWER, UPPER 6 FLOORS



490024 01/21/2009

ROANOKE, VA 24033






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South Building, New

Description of structure: 7 Story Building


Sprinkler Status: Sprinklered






the LSC 2000 New regulations. The facility was

not in compliance with the Requirements for





Fire.)










K 011

Based on observations, the facility failed to enure

that the fire barrier wall was maintained between

buildings. This violation affected 1 of 3 exits.

Findings include:








A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






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On 11-3-08, it was revealed by observation that

there is an improper separation. This occurred in

the following locations:

at approximately 1512 hrs. - On 15th floor at the

flight storage cage, the building separation wall

appears to be constructed as a one hour rating.


there were unprotected penetrations and

improperly sealed joints. This occurred in the

following locations:

15th Floor:

at approximately 1003 hrs. - Penetrations in 2

hour firewall above entrance to data room, across

entire wall in data room.

at approximately 1009 hrs. - Fire wall not

complete in data room.

at approximately 1013 hrs. - Penetrations 2 hour

fire wall above storage room.

13th Floor:

at approximately 1127 hrs. - Penetrations to 2

hour firewall without fire damper in women ' s

locker room.


there were unprotected penetrations improperly

latching doors and improperly sealed joints. This

occurred in the following locations:

12th Floor:

at approximately 1035 hrs. - Environmental


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

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Services outside of electrical room above ceiling

2 hour firewall not sealed at concrete decking.

11th Floor:

at approximately 1507 hrs. - 1 leaf of fire doors is

not latching.

at approximately 1510 hrs. - several penetrations

in what appears to be the firewall next to the

Director ' s office.


there were unprotected penetrations and

improperly sealed joints. This occurred in the


10th Floor:

at approximately 1059 hrs. - Two-hour fire barrier

above double doors leading from Mountain

Pavilion to South Pavilion have multiple

unprotected penetrations.

at approximately 1100 hrs. - There are

unprotected penetrations in the two-hour fire

barrier wall outside of storage room at Stairwell 2.


in corridor that leads from South to Mountain only

has 20-minute listed fire-rated doors that required

at least an hour and a half.

at approximately 1250 hrs. - East to South

breezeway there is no two hour fire barrier

between buildings.

at approximately 1250 hrs. - there are

unprotected penetrations in the two-hour fire


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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(X4) ID

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barrier going into Mountain.


that enters into West Pavilion has multiple

unprotected penetrations that have used different

types of fire caulking and it is not properly sealed

at the deck.


at stairwell is not sealed all the way to the

decking.




buildings.





of the following: 18.1.6.2, 18.1.6.3, 18.2.5.1


K 012

Based on observation, it was revealed that the

facility failed to maintain fire barrier having at

least a two-hour fire resistance rating. This

violation affects the entire building.

Survey findings include:


the facility failed to maintain the required type of

construction. This occurred in the following


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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(X4) ID

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locations:

15TH Floor:

at approximately 1346 hrs. - Unprotected

penetrations to floor behind ANSUL system in

mechanical room.


penetration to the exterior corner back wall at

helipad in mechanical room.

at approximately 1429 hrs. - Fire proofing missing

on bottom of the beam in corridor.

at approximately 1424 hrs. - Fire proofing missing

on columns in mechanical room.


penetration to the floor at the steps in mechanical

room.




locations:

15th Floor:

at approximately 1012 hrs. - Wood in construction

and fire proofing missing on structural steel in

data storage room.


penetrations to the floor assembly in the old

elevator penthouse.

at approximately 1112 hrs. - Fire proofing is

missing from structural steel at clamps for lights

and conduit feed fire panel in the data closet at


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





women's locker room.

at approximately 1112 hrs. - The expansion joint

is not properly sealed in the data closet at women

' s locker room.


penetrations in floor/ceiling assembly in data

room.



room behind kronos station.

13th Floor:


penetrations in floor/ceiling assembly in janitor's

closet.


penetrations in floor/ceiling assembly in triage.


penetrations in floor/ceiling assembly before exit

door in elevator lobby.


penetrations in floor/ceiling assembly in

equipment room next to staff lounge.




locations:

12th Floor:


missing from structural steel in 2 hour fire barrier


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





at Environmental Services and Lactation

Consultants' office.


penetrations in floor/ceiling assembly in

Environmental Services Room.


penetrations in floor/ceiling assembly in corridor

above the water fountains around from the

elevator.



closet also combustible foam inside penetrations

in ceiling.


penetrations in floor/ceiling assembly in staff

locker room across from nurses' station.


penetrations in floor/ceiling assembly in electrical

Room, we need a manufacturer' s cut sheet for 3

green penetrations for a floor ceiling slab.


penetrations in floor/ceiling assembly above the

duct work in the alcove behind the 2 hour shaft.

at approximately 1357 hrs. - fire proofing is

missing from the structural steel in clean utility

room.


missing from structural steel in environmental

services electrical closet.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

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room.




locations:

11th Floor:


penetrations in floor/ceiling assembly in the very

end of the corridor outside of the Pediatric

Therapy Office.


penetrations in floor/ceiling assembly in electric

room.


penetrations in floor/ceiling assembly in electrical

room.


penetrations in floor/ceiling assembly in clean

utility room.




locations:

11th Floor:


penetrations in floor/ceiling assembly in corner of

the radius outside of Environmental Services.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

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penetrations in floor/ceiling assembly in radius

above room 1142.

10th Floor:



room.


missing from structural steel in the two-hour fire

separation going into Mountain.


penetrations in floor/ceiling assembly in the rest

rooms outside the Director of Oncology Services

office.


missing from structural steel in entire length of

East/South breakthrough.


penetrations in floor/ceiling assembly at the

junction between the three buildings.




Corridor walls form a barrier to limit the transfer of

smoke. Such walls are permitted to terminate at

the ceiling where the ceiling is constructed to limit

the transfer of smoke. No fire resistance rating is

required for the corridor walls. 18.3.6.1,

18.3.6.2, 18.3.6.5

K 017


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

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Finding Include:

14th Floor


penetrations to smoke partition in women's locker

room.


penetrations to smoke partition in pod-B above

Nurse Call.


penetrations to smoke partition at main entrance.


penetrations to smoke partition at snack

machines

in Ronald McDonald room.

15th Floor:


penetrations to smoke partition inside flight cage

storage.


the facility failed to maintain corridor walls to limit

the transfer of smoke. This occurred in the


15th Floor:



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





penetrations to smoke partition over janitor's

closet.


penetrations to smoke partition in data room.

13th Floor:


penetrations to smoke partition in janitor's closet

off elevator.


penetrations to smoke partition in triage.


penetrations to smoke partition outside of OB

cross corridor doors. Cross corridor and corridor

walls don't meet.

at approximately 1322 hrs. - Cross corridor doors

and corridor walls don't meet at OB entrance.


penetrations to smoke partition in report room.


penetrations to smoke partition next to window in

share storage behind Share office.





12th Floor:


penetrations to smoke partition at restroom next

to elevators


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

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at approximately 1310 hrs. - Unsealed joints and

unprotected penetrations in smoke partition at

nurse's station.


penetrations to smoke partition around the corner

from the elevator lobby across from the restroom.





11th Floor:


penetrations to smoke partition in play room.


penetrations to smoke partition in room 1157.

at approximately 1323 hrs. - The smoke partition

is not properly sealed at the deck in room 1157.





11th Floor:


is not properly sealed at the deck in the radius

outside of the Clean Utility Room and at room

1137.


is not properly sealed at the deck in the radius


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

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outside of Environmental Services.


is not properly sealed at the deck above Director

of Pediatric Services ' office.


penetrations to smoke partition in nourishment

area.


is not properly sealed at the deck in hallway

outside of the elevator lobby.


penetrations to smoke partition in hallway outside

of the elevator lobby


penetrations to smoke partition in East/South

breakthrough about halfway down on the left.


penetrations to smoke partition in East/South

breakthrough 3/4th down the corridor through the

wall.

10th Floor:


penetrations to smoke partition outside the

Director of Oncology Services' office.


is not properly sealed at the deck in hallway

outside on-call room and the conference room.


penetrations to smoke partition outside on-call


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

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TAG





room and the conference room.


is not properly sealed at the deck in exam room.


penetrations to smoke partition in environmental

service closet at smoke barrier wall


is not properly sealed at the deck in

environmental service closet at smoke barrier

wall.


penetrations to smoke partition in hallway leading

to the service elevators.


penetrations to smoke partition in electrical

closet.


is not properly sealed at the deck in electrical

closet.


penetrations to smoke partition outside the

consult conference room.


is nonexistent to the deck in the nurses' station.


penetrations to smoke partition in staff restrooms.


is not properly sealed at the deck in staff

restrooms.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG









10th Floor:


is not properly sealed at the deck in corridor

outside of rooms 1035/1036.



outside of room 1034.



inside the nourishment area on the back side of

the nurses' station.


penetrations to smoke partition inside the

nourishment area on the back side of the nurses'

station.


penetrations to smoke partition at the nurses'

station across from room 1059.


is not properly sealed at the deck at the nurses '

station across from room 1059.


penetrations to smoke partition in 1055.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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(X4) ID

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compartments.




Doors protecting corridor openings are

constructed to resist the passage of smoke.

Doors are provided with positive latching

hardware. Dutch doors meeting 18.3.6.3.6 are

permitted. Roller latches are prohibited.

18.3.6.3


K 018




Findings include:


the facility failed to maintain corridor doors to limit



13th Floor:

at approximately 1422 hrs. - The door to room

1339 is not positive latching.






A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





12th Floor:



at approximately 1422 hrs. - The door to staff

locker room is not positive latching.





11th Floor:









10th Floor:

at approximately 1342 hrs. - The door to the

Environmental Services room is held open by a

shelf that is just inside the door.





at approximately 1000 hrs. - The doors on all

floors in the radius are not capable of latching.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

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Appears to be 10 patient rooms per floor.









having a fire resistance rating of at least two

hours connecting four stories or more. (One hour

for single story building and sprinklered buildings

up to three stories in height.) 18.3.1.1.

An atrium may be used in accordance with

8.2.2.3.5.


K 020




Findings include:

14th Floor:


penetrations to 2 hour vertical shaft in 1433 Pod

A of NICU.

15th Floor:

at approximately 1510 hrs. - Door into shaft was


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





disabled and not self closing in mechanical room.

at approximately 1435 hrs. - Damage to the 2

hour shaft wall in elevator penthouse.


penetrations to 2 hour vertical shaft in flight cage

storage.


penetrations to shaft #2 by communications

cable.


the facility failed to maintain fire resistance rating

of vertical shaft walls. This occurred in the


15th Floor:


penetrations to 2 hour vertical shaft in elevator

lobby.


penetrations to 2 hour vertical shaft in mechanical

room at stairwell 11.


penetrations to 2 hour vertical shaft in stairwell

11.

13th Floor:


penetrations to 2 hour vertical shaft in room 1331.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG







12th Floor:


penetrations to 2 hour vertical shaft in staff locker

room across from nurses ' station.


penetrations to 2 hour vertical shaft in stairwell 12

at main entrance at nurse ' s station.

at approximately 1300 hrs. - Vertical shaft at

stairwell 12 is not properly sealed to the deck.


penetrations to 2 hour vertical shaft in elevator

lobby.

at approximately 1335 hrs. - Fire stopping is not

complete to the 2 hour vertical shaft in elevator

lobby.

11th Floor:

at approximately 1445 hrs. - Fire stopping is not

complete to the 2 hour vertical shaft outside of

the elevator lobby at the rear exit door.


penetrations to 2 hour vertical shaft outside of the

elevator lobby at the rear exit door.






A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





11th Floor


penetrations to 2 hour vertical shaft in stairwell 12

at main entrance at nurse ' s station.

at approximately 1445 hrs. - The 2 hour vertical

shafts decrease in size as they extend upward.

Documentation needs to be supplied that at each

level the fire resistance is maintained and the

shaft liner was installed according to the

manufacturer ' s specifications.


penetrations to both 2 hour mechanical shafts at

the nurses ' station.

at approximately 1442 hrs. - A piece of the shaft

liner is damaged in the 2 hour mechanical shaft at

the nurses ' station.

at approximately 1419 hrs. - The floor area of the

2 hour mechanical shaft is broken compromising

the 2 hour rating.


penetrations to the walls of a 2 hour vertical shaft

by steel beams holding the duct work up in the

left elevator, left shaft





10th Floor:


penetrations to 2 hour vertical shaft in data room.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG













occupants. 7.10.1.4


K 022



Findings include:


the facility failed to maintain clearly marked exits.

This occurred in the following locations:

13th Floor:

at approximately 1430 hrs. - a clear travel path is

not marked at the rear exit door.




11th Floor:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






not marked at the side exit.




13th Floor:


not marked at the patient/visitor lounge, through

that cross corridor.




13th Floor:

at approximately 1350 hrs. - the exit light is

obstructed at double doors to the front stairwell.







least a one-hour fire resistance rating in




panels in approved frames. A minimum of two




K 025


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






18.3.7.3, 18.3.7.5, 18.1.6.3




Findings include:

12th Floor:


penetrations to the smoke barrier wall Clinical

Specialist ' s office.


penetrations to the smoke barrier wall in Unit

Director ' s office.


penetrations to the smoke barrier wall above the

corridor doors at rooms 1247 and 1261.



of smoke barrier walls. This occurred in the


11th Floor:


penetrations to the smoke barrier wall in back wall

of electrical room.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG







of smoke barrier walls. This occurred in the


10th Floor:


penetrations to the smoke barrier wall outside of

room 1063.


penetrations to the smoke barrier wall in the

Family Resource Room.

at approximately 1430 hrs. - Smoke barrier wall is

not properly constructed in the Family Resource

Room. There is missing gypsum.




compartment.




Hazardous areas are protected in accordance

with 8.4. The areas are enclosed with a one hour

fire-rated barrier, with a 3/4 hour fire-rated door,

without windows (in accordance with 8.4). Doors

are self-closing or automatic closing in

accordance with 7.2.1.8. 18.3.2.1


K 029



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






Findings include:


the facility failed to maintain hazardous areas in

accordance with 8.4. This occurred in the


15th Floor:


penetrations to the hazardous area wall in data

room.

at approximately 1007 hrs. - Hazardous area

walls are not properly sealed to the deck in data

room.

13th Floor:


penetrations to the hazardous area wall in

equipment storage room at Pyxis.


penetrations to the hazardous area wall in clean

utility room.


walls are not properly sealed to the deck and

between gypsum joints in clean utility room.


penetrations to the hazardous area wall in

equipment room next to staff lounge.


penetrations to the hazardous area wall in soiled


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





utility across from nurses' station.





12th Floor:


penetrations and walls not properly sealed at

deck in a hazardous area in environmental

services storage room.


walls are not properly sealed to the deck above

Pyxis unit in clean supply.


walls are not properly sealed to the deck in linen

closet.


walls are not properly sealed to the deck in clean

utility room above the built-in cabinets.



deck in soiled utility room.


walls are not properly sealed to the deck in

storage room at the end of the hallway.

11th Floor:


penetration to the door in storage room at rear

exit off of elevator lobby..


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG









11th Floor:



deck in a hazardous area in soiled utility room in

the radius.

10th Floor:



deck in a hazardous area in storage data room at

the fire barrier.



deck in a hazardous area in storage room across

from nurse/educator's office.



deck in a hazardous area in environmental

services room, outside of nurse/educator ' s and

Clinical Team Leader's office.


penetrations and walls nonexistent to the deck in

a hazardous area in the soiled utility room at

nurses' station.


penetrations to the hazardous area wall in clean

storage across from nurses' station.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG







deck in a hazardous area in clean utility room.





10th Floor:


walls are not properly sealed to the deck in staff

storage room.



deck in a hazardous area in soiled utility room

across from room 1036.



deck in a hazardous area in staff storage room at

the stairwell 11.





13th Floor:

at approximately 1330 hrs. - In the anesthesia

storage room there are unprotected penetrations

to the hazardous area walls, there is no door

closure and the door frame and door do not have

a fire rating.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





at approximately 1330 hrs. - In the OR prep area

storage room there are unprotected penetrations

to the hazardous area walls, there is no door

closure, the wall construction does not meet

required rating and the door is not capable of

latching.



are located.






7.1. 18.2.1


K 038



accessible.

Findings Include:


the facility failed to arrange exits that are readily

accessible at all times. This occurred in the


at approximately 0900 hrs. - There is no stairwell

accessible from the helipad without traveling

through locked doors or rooms.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





patients on the 15th floor of the building..




Width of aisles or corridors (clear and

unobstructed) serving as exit access in hospitals

and nursing homes is at least 8 feet. In limited

care facilities and psychiatric hospitals, width of

aisles or corridors is at least 6 feet. 18.2.3.3,

18.2.3.4


K 039


maintain the aisles or corridors serving as exit

access to at least 8 feet in width.

Findings Include:


the facility failed to maintain required width of

corridor at all times. This occurred in the


13th Floor:

at approximately 1125 hrs. - Boxes on the floor

and storage in the hallway outside of elevators.


the facility failed to maintain egress free from

obstructions. This occurred in the following

locations:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





11th Floor:

at approximately 1440 hrs. - Storage in the

corridor outside of elevator lobby.

12th Floor:

at approximately 1300 hrs. - Storage in the

corridor outside of elevator lobby. Storage was

removed. Items were placed back in that area.


patients in the affected compartment of the

building..








K 048




Findings Include:


the facility failed to maintain written emergency

procedures at each nurses' station. This


All nurses' stations on all floors


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





at approximately 1500 hrs. - There are no written

emergency manuals being maintained at the

nurses' station.






A fire alarm system with approved components,

devices or equipment is installed according to

NFPA 72, to provide effective warning of fire in

any part of the building. Activation of the

complete fire alarm system is by manual fire

alarm initiation, automatic detection, or

extinguishing system operation. Pull stations are

located in the path of egress. Electronic or

written records of tests are available. A reliable

second source of power is provided. Fire alarm

systems are maintained in accordance with NFPA

72, National Fire Alarm Code, and records of

maintenance are kept readily available. There is

remote annunciation of the fire alarm system to

an approved central station. 18.3.4, 9.6


K 051

Based on observations made on 1/6/09, the

facility failed to maintain a complete fire alarm

system.

Findings include:


the facility failed to install the fire alarm system in


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

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accordance with 18.3.6.1. This occurred in the


13th Floor:

at approximately 1415 hrs. - Nutrition center open

to corridor, does not have detection,.

at approximately 1430 hrs. - Nourishment Room,

across from room #1354, does not have smoke

detection.

at approximately 1424 hrs. - Med station room is

open to corridor, does not have detection.


the facility failed to install the fire alarm system in

accordance with 18.3.6.1. This occurred in the


11th Floor:

at approximately 1014 hrs. - Nourishment area is

open to the corridor and does not have a smoke

detection in PICU.

at approximately 1437 hrs. - Med station room

does not have smoke detection.






A fire alarm system required for life safety is

installed, tested, and maintained in accordance

with NFPA 70 National Electrical Code and NFPA

K 052


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

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72. The system has an approved maintenance

and testing program complying with applicable

requirements of NFPA 70 and 72. 9.6.1.4


Based on observation, the facility failed to

maintain the fire alarm system in accordance with

NFPA 70 and NFPA 72.

Findings include:

On 10-15-08, based on documentation provided

by Carilion, the facility failed to maintain the fire

alarm system in accordance with NFPA 70 and

NFPA 72.

at approximately 0900 hrs. - The fire alarm

system is being tested; however, the report does

not conform to requirements set forth in NFPA 72.











K 054


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

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Findings include:

On 10-15-08, based on information provided by

Carilion, the facility failed to maintain all required

smoke detectors.

at approximately 0900 hrs. - Smoke detectors are

not being tested for sensitivity rating as required.

Also, the report is not in an acceptable format as

required by NFPA 72.






There is an automatic sprinkler system, installed

in accordance with NFPA 13, Standard for the

Installation of Sprinkler Systems, with approved

components, devices, and equipment, to provide

complete coverage of all portions of the facility.

The system is maintained in accordance with

NFPA 25, Standard for the Inspection, Testing,

and Maintenance of Water-Based Fire Protection

Systems. There is a reliable, adequate water

supply for the system. The system is equipped

with waterflow and tamper switches which are

connected to the fire alarm system. 18.3.5.

K 056


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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ensure that the building was fully sprinklered.

Findings include:


the facility failed to install automatic sprinkler

system in accordance with NFPA 13. This


15th Floor:

at approximately 1022 hrs. - No sprinkler

coverage, data room, at door to old elevator

penthouse.

at approximately 1019 hrs. - Incomplete sprinkler

coverage old elevator penthouse.








periodically. 18.7.6, 4.6.12, NFPA 13, NFPA 25,

9.7.5


K 062




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

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Findings include:


the facility failed to maintain automatic sprinkler

system in accordance with NFPA 13 and NFPA

25. This occurred in the following locations:

14th Floor:

at approximately 0935 hrs. - Escutcheon plate

missing at stairwell door.

15th Floor:

at approximately 1326 hrs.- Stand pipe cap

missing from the helipad.





12th Floor:

at approximately 1030 hrs. - Wires connected to

sprinkler piping hanger in environmental services

room.

at approximately 1040 hrs. - Wires connected to

sprinkler piping in corridor outside environmental

services room.


missing in interior environmental services closet.

11th Floor:


missing in hallway 11 outside of elevator lobby.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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10th Floor:

at approximately 1010 hrs. - There are wires

draped over sprinkler piping, which is deforming

the pipe in the radius at nurses ' station outside

of the staff conference room.

at approximately 1248 hrs. - Sprinkler is within 4

inches to a sign in the walkway between

Mountain, South Tower, and East.


missing outside nurse/educator ' s office.


missing in the Environmental Services room.





13th Floor:


missing in OR prep room.







A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

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Smoking regulations are adopted and include no

less than the following provisions:

(1) Smoking is prohibited in any room, ward, or

compartment where flammable liquids,

combustible gases, or oxygen is used or stored

and in any other hazardous location, and such

area is posted with signs that read NO SMOKING

or with the international symbol for no smoking.

(2) Smoking by patients classified as not

responsible is prohibited, except when under

direct supervision.

(3) Ashtrays of noncombustible material and safe

design are provided in all areas where smoking is

permitted.

(4) Metal containers with self-closing cover

devices into which ashtrays can be emptied are

readily available to all areas where smoking is

permitted. 18.7.4


Based on observations, the facility failed to adopt

and include smoking regulations within the

following provisions.

Findings Include:


the facility failed to maintain smoking regulation

adopted by the facility. This occurred in the



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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13th Floor:

at approximately 1147 hrs. - Smoking material

was observed in janitor's closet on top of ceiling

tile.


the facility failed to maintain smoking regulation

adopted by the facility. This occurred in the


12th Floor:

at approximately 1357 hrs. - Smoking material

was observed in nurses' room on top of gypsum

tile.









specifications. 9.2, 18.5.2.1, 18.5.2.2, NFPA

90A


K 067



specifications.

Findings Include:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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ROANOKE, VA 24033






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the facility failed to install and maintain heating

and air conditioning systems as required by NFPA

101 and NFPA 90A. This occurred in the


at approximately 0830 hrs. - The corridors on all

floors are being used as return air plenums.

at approximately 0830 hrs. - Documentation was

not available that all fire/smoke dampers are

being tested in accordance with NFPA 90A.

14th Floor NICU:

at approximately 1045 hrs. - There are no

smoke/fire dampers installed in duct work

penetrating a rated wall that opens into the clean

utility room.




storage room.



penetrating a rated wall that opens into the soiled

utility room.






15th Floor:



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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penetrating the 2 hour rated fire barrier in the data

room.

at approximately 1235 hrs. - Wood was observed

in the plenum space in triage,



penetrating a rated wall that opens into the Pyxis

storage room




utility room.




utility room at visitor ' s elevator.




utility room across from the nurses ' station.






12th Floor:

at approximately 1305 hrs. - The signage

indicating the location of the fire damper is not in

place, near the shaft off of the nurse ' s station.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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supply room behind the nurse ' s station.




linen room.




utility room.




utility room.



penetrating the 2 hour rated fire barrier at the

environmental services interior corridor.



penetrating a rated wall that opens into the

storage room at the end of the hallway.

11th Floor:




storage room outside of Director ' s office.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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11th Floor:




utility room.






11th Floor:




utility room in the radius.

10th Floor:



penetrating the 2 hour rated fire barrier at the

data room.


in the plenum space in where the breezeway

turns heading towards East Pavilion.




environmental services storage room, outside of


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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nurse/educator ' s.




utility room.







in the plenum space in patient rooms for the

equipment track, floors 10 -14.




storage room for staff only at stairwell 11.






13th Floor:




anesthesia storage room.



penetrating a rated wall that opens into the OR

prep storage room.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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ROANOKE, VA 24033






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Means of egress are continuously maintained free

of all obstructions or impediments to full instant

use in the case of fire or other emergency. No

furnishings, decorations, or other objects obstruct

exits, access to, egress from, or visibility of exits.

7.1.10


K 072


maintain the means of egress free of all

obstructions.

Findings Include:




locations:

15th Floor:

at approximately 1514 hrs. - Storage in elevator

lobby.




locations:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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11th Floor:

at approximately 1345 hrs. - There is a movable

wooden cabinet-5 foot tall, 3 feet wide in the

corridor outside of the teen room.









K 073




Findings Include:

On 11-06-08, at approximately 1340 hrs, on the

11th floor. - There is no documentation the couch

in the corridor outside of conference room/teen

room is flame retardant.



are located.





99, Chapter 4.

K 077


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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installed properly.

Findings include:


the facility failed to maintain medical gas in

accordance with NFPA 99. This occurred in the


10th through 14th Floors:

at approximately 0830 hrs. -Medical gas piping is

not properly marked.









K 147



with NFPA 70.

Findings Include:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

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the facility failed to maintain electrical wiring in

accordance to NFPA 70. This occurred in the


15th Floor:

at approximately 0955 hrs. - 4" square junction

box in ceiling with no cover in data storage room.

13th Floor:

at approximately 1452 hrs. - Cover missing to a

4" x 8" electrical box in room 1354.





12th Floor:


box in ceiling with no cover in environmental

services room.

at approximately 1053 hrs. - Exposed wiring in

ceiling at elevator at 6-bank elevators.

at approximately 1425 hrs. - Temporary lighting

still intact in the concealed space in secretary's

office.

11th Floor


box in ceiling with no cover in Data Room beside

6 bank elevator:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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11th Floor:

at approximately 1035 hrs. - Open wire splices at

stairwell 11.





11th Floor:

at approximately 1021 hrs. - 4 Power strips are

piggybacked behind one of the physician's desks

in the Doctor's office.

10th Floor:

at approximately 1116 hrs. - Junction box does

not have an approved cover and has open wire

splices in hallway outside of elevator lobby.





13th Floor:

at approximately 1335 hrs. - Temporary lighting

still intact in the concealed space of anesthesia



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

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Where Alcohol Based Hand Rub (ABHR)

dispensers are installed in a corridor:

o The corridor is at least 6 feet wide

o The maximum individual fluid dispenser

capacity shall be 1.2 liters (2 liters in suites of

rooms)

o The dispensers shall have a minimum spacing

of 4 ft from each other

o Not more than 10 gallons are used in a single

smoke compartment outside a storage cabinet.

o Dispensers are not installed over or adjacent to

an ignition source.

o If the floor is carpeted, the building is fully

sprinklered. 18.3.2.7, CFR 403.744, 418.100,

460.72, 482.41, 483.70, 483.623, 485.623


K 211


ensure that alcohol based hand rub dispensers

are installed properly.

Findings include:


10th through 14th Floor:

at approximately 0900 hrs. - 50 - 60 percent of

the Alcohol Based Hand Rub stations were

installed over or adjacent to light switches or

electrical outlets.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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This has the potential to affect the staff and

patients in the entire building.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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DEFICIENCY)

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West Building

Description of structure: 15 Story Building,


Sprinkler Status: Partially Sprinklered








Participation Medicare and Medicaid. The

findings that follow demonstrate non-compliance

with Title 42 Code of Regulations, 482.41(b) et

seq (Life Safety from Fire.)










K 011



between buildings.

Findings include:









A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

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was observed that on the Ground lobby

level, behind the Information Desk, at the Parking

Deck connector separation door and

above the ceiling that there is one area on the

right-hand side as you ' re looking towards the

parking deck with a section of block missing at

the corner. The two-hour rated wall is not

complete to the overhead deck. In the left corner

is the same condition. These areas are not

complete and not properly fire stopped.


was observed that on the 1st floor, at the

main lobby glassed-in entry near the Information

Desk there is no rated separation between

the South and West buildings.


was observed that on the 1st floor, the main

entry lobby Atrium is not properly separated

between the West and the South buildings. The

construction does not appear to meet the

separation rated assembly requirements between

buildings.


was observed that on the 1st floor, W2 stairwell,

the corridor between the stairs and the courtyard,

above the door to infectious control, there are

multiple unsealed penetrations.


was observed that on the 1st floor, door from

Infectious Control to the W2 Stairwell corridor,

has a 20 minute rated door. This should be a 1.5

hour rated door.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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buildings.





of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4,

19.3.5.1


K 012



maintained.

Findings Include:



the ceiling in the elevator lobby is one steel beam

has had the fireproofing removed for a

mechanical line and some electrical grounding

attachments.



top of the shaft in the mechanical room, there is

poly sheeting attached to the wall with duct

tape. It has spray-on fireproofing over the top of

that, at the top of the concrete block wall.



Pharmacy Specialist office has three 4 " conduits

penetrating the fire-rated ceiling. The ends


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






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of the conduits are open, and there ' s no fire

stopping in the ends. There is also one ¾ "

conduit penetration near the other one without

proper fire stopping.



smoke doors at room 1228, on the right-hand

side as you ' re looking from the smoke

compartment away from the nurses ' station,

there is spray-on fireproofing that has been

removed and needs to be replaced.


was observed that on the 12th floor, near room

1207, above the drop ceiling, poly sheeting from

the drop ceiling to the spray-on fire

proofed beam was in place. This sheeting does

not appear to be flame retardant.


was observed that on the 12th floor, the non-fire

rated poly sheeting appears everywhere the

Z-spline ceiling transitions to the drop-in tile grid

ceiling. That ' s in at least four locations

throughout the 12th floor.



electrical closet across from room 1108, a piece

of ½ " conduit penetration through the rated

floor is fire stopped with expandable foam.





ceiling. That ' s in at least four locations

throughout the 10th floor.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






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Phlebotomy area has the overhead structural

steel did not have spray-on fireproofing to

maintain the 2-hour separation required for the

floor above.



Electrical closet near panel 8A has a ¾ "

electrical conduit penetration through the

overhead

deck that ' s not properly fire stopped.



telephone equipment room has Penetrations from

data and telephone cabling running

through the ceiling and two back boxes aren't



was observed that on the 6th floor, there ' s a

room marked as storage beside the linen storage

room. This room actually is a

telephone/interface equipment room. It was found

to have two penetrations, one from data

cable and telephone cable coming through the

rated overhead deck.



electrical closet across from room 608 has

conduit penetrations through the floor with three

different kinds of the fire-rated caulking

overlapping each other.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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DEFICIENCY)

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DATE

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the ceiling outside of the staff elevators, many

penetrations through the upper deck, the

spray-on fireproofing does not appear to be

complete, and many of the penetrations have

been stuffed with fiberglass insulation and not




the drop ceiling in room 402 that one 2 " hole is

penetrating the overhead deck, is not

properly fire stopped. There was found a large

piece of sheet rock on the side wall right over

the door to room 402, which has come loose and

is not intact. There are several other

penetrations in this area that aren't properly fire

stopped.



floor penetration by electrical conduit and data

cabling that there are two different types of

fire caulking overlapping each other which

improperly fire stop the penetration.



electrical closet was found to have a penetration

by data cable and electrical wires through

the overhead deck which is not properly fire

stopped. The overhead spray-on fireproofing is

not complete.



corridor outside of room 410 at the nurses '

station wall, above the ceiling the structural steel

spray-on fireproofing has come off from a steel


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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beam, and a flange just across from that.

There appears to be a hole burned through the

steel beam where the fire proofing is missing.


was observed that on the 3rd floor in the

Morgue area the Environmental Services closet

has a hard drop-in style tile missing in the

ceiling. There also are poly-sheeting barriers

between this area and the spline-type ceiling

out in the corridor. This poly-sheeting is being

utilized to present a barrier to the area that

contains asbestos above the ceilings. This

sheeting however, was observed to contain big

holes in it and does not appear to be

fire-retardant plastic.


was observed that on the on the 3rd floor in

the Morgue area above the drop ceiling the

overhead decking spray-on fireproofing is not

complete.



Morgue area, in the dissection room above the

ceiling at the corridor wall, the overhead

decking spray-on fireproofing is not complete.


was observed that on the 2nd floor above

the staff elevator lobby ceilings there are 3

penetrations through the overhead deck that are



was observed that on the 2nd floor above

the double doors the spray-on fireproofing is not

complete.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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was observed that on the 2nd floor at

Stairwell #3, in the storage closet off the corridor

the two-hour rated wall is not complete to

the overhead deck from the storage room back

towards the main elevator lobby.


was observed that on the 1st floor above the

double fire-rated doors there is a two-hour rated

partition with a large penetration by a data cable

tray. This tray has been sealed with acoustic

sealing tile, and it is improperly fire stopped.


was observed that on the 1st floor in

stairwell #1 above the drop ceiling in the corridor

five or six penetrations by electrical

conduits through the block wall without proper fire

stopping.



Office of Academic Affairs entryway that the

two-hour rated mechanical shaft above the

drop ceiling is not complete to the floor. Above

the ceiling it was revealed that there is no

rated construction at the bottom of the shaft and

the shaft appears to carry through to three or four

floors above.



level behind the Information Desk in the electrical

equipment room above the drop ceiling,

there is 2 or 2 ½" core drilled hole through the

overhead deck that is not properly fire

stopped. It was also witnessed the smoke wall


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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over the entry door to the closet has two -

¾"conduits penetrating through the wall and are

not properly fire stopped. The ends of the

conduits are not fire stopped, and the top of the

wall is not properly fire stopped at the

corrugated decking.



level behind the Information Desk, in the electrical

equipment room there is one small open

penetration through the concrete block for the

elevator shaft wall, above the ceiling in the

electrical closet, about 6 " above the ceiling. This

hole is not properly fire stopped.



level in the Administrative offices in one small

office next to the rated wall for the escalator

that above the drop ceiling the spray-on

fireproofing has been removed from the overhead

beam for hanger clamps. This included two for a

duct and one for a sprinkler line. The

spray-on fire proofing is not complete.



Janitor's Closet behind the old Gift Shop area

does not have ceiling tiles installed in the drop

ceiling.



Staff Elevator lobby above the ceiling that the

spray-on fire proofing is not complete on the

hanger clamps in this area.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

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was observed that on the 1st floor, above the

ceiling at the double doors at the West & South

building separation that the spray-on fire

proofing had been removed and is not complete.


was observed that on the Basement Level,

the drop ceiling tiles are missing above the

sprinkler riser.



multiple penetrations in the overhead decking are



was observed that on the Basement Level, in the

Mechanical room, that the spray-on fire proofing

is not complete in multiple locations.


was observed that on the 15th floor, there is a

penetration in the wall near the Verizon office,

that is covered with what appears to be plastic

sheeting. This plastic sheeting also has spray-on

fire proofing material applied to it.


was observed that on the 13th floor, service/staff

elevator lobby, penetrations in the rated floor

above that are not sealed. Spray-on fire proofing

material is also missing from steel in this area.


was observed that on the 13th floor, W2 Stairway,

above the drop ceiling, going to the south tower

connector, that structural steel does not have

spray-on fire proofing applied.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






was observed that on the 12th floor, near the

service/staff elevators, penetrations that are

sealed with several different types of material,

which are over-lapping each other.



staff/service elevators, above the drop ceiling,

there is wood on the corrugated steel to the floor

above.



staff/service elevators, there is wood on the

corrugated steel to the floor above.


was observed that on the 9th floor, near patient

room 904, there is plastic sheeting material above

the drop ceiling, which is being used to separate

the asbestos contaminated area from the

non-contaminated area. Documentation is

needed to determine if this plastic is

non-combustible.


was observed that on the 9th floor electrical room,

at panel 9B, across from patient room 908, there

is a penetration in hard ceiling by network cables

that is not sealed.


was observed that on the 8th floor, W2 Stairway,

above the drop ceiling, going to the south tower

connector, that structural steel does not have

spray-on fire proofing applied.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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above.





above.


was observed that on the 6 west, Clinical Team

Leaders Office, there is a piece of ceiling tile that

is not in place. This is a sprinklered office.





above.


was observed that on the 5th floor, data room,

next to patient rooms 508 and 509, unsealed

penetrations where a large electrical conduit

penetrates the wall. There is also penetrations

that have been sealed with different types of

material, that are touching each other.


was observed that on the 5th floor, near the main

elevator bank, the fire department connection box

has penetrations in the box, which need to be

sealed, to maintain the rating of the box.





A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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(X4) ID

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there is a penetration that is sealed with an

unapproved material, a paper bag, not a fire rated

material.



across from patient room 419, there is no

spray-on fire proofing on any of the structural

steel in this room.


was observed that on the 4th floor, patient room

415, above the drop ceiling, there is plastic

wrapped around the electrical cable, at the

junction box.




there is a steel structural beam that does not

have any fire-proofing material on it.


was observed that on the 3rd floor, laboratory,

microbiology electrical closet, there is structural

steel that is not protected.



near the automated area, computer work station,

there is a large hole in the rated floor. This would

be considered a penetration in a 2 hour floor

assembly.


was observed that on the 2nd floor, Radiology

holding area between corridor, patient areas 3

and 4, unprotected structural steel above the drop

ceiling.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

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was observed that on the 2nd floor, above the

corridor drop ceiling, near Ultrasound 3, there is

combustible wood supporting electrical conduit.


was observed that on the 2nd floor electrical

room, near Ultrasound 3, unsealed penetrations

by electrical conduit, in the drywall ceiling.


was observed that on the 2nd floor, data room in

Xray, next to Ultrasound 4, ceiling tiles are not in

place, with cables running up into the ceiling.


was observed that on the 1st floor, near the


looking back towards administration, there is

combustible material, plastic, that has been left in

this area.


was observed that on the ground floor, elevator

lobby, above the concealed ceiling space, there is

wood blocking in this area.


was observed that on the ground floor, gift shop,

above the drop ceiling, there is plastic in this

area, wrapped around some of the pipes.


was observed that on the ground floor, old snack

bar, this room has been changed from a snack

bar, which was removed, and is now being used

for storage. The ceiling tiles are not in place and

there are also unsealed penetrations.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






was observed that on the basement area, old

shop area, ceiling tiles are not in place.


was observed that on the basement level,

mechanical room, at air handler unit 18, heading

back between that and 19, behind fan 1S, there '

s is a an access door that goes to the tunnel. This

door was open at the time of inspection and does

not have a closer or latch.



mechanical room, to the right of air handler 18,

there is a fire damper in the ceiling with no

documentation of service.



mechanical room, to the right of air handler 17,

there is a fire damper in the ceiling with no

documentation of service.



mechanical room, cage area, next to air handler

22, there is plywood covering a hole in the rated

floor above. There is also fire-proofing missing

from the structural steel in this area.


was observed that on the basement, mechanical

room, next to air handler 23, there is plywood

covering a hole in the rated floor above. There is

also fireproofing missing from the structural steel

in this area.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG







mechanical room, next to air handler 23, there is

a duct which is penetrating a rated assembly,

without a damper.


was observed that on the 13th floor, Conference

Room A, electrical room, there is plastic sheeting

above the drop ceiling, encapsulating the

asbestos area.




compartments.













19.3.3.2


K 015




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

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Findings Include:



Mechanical room, that inside wiring junction box

BA there were two wooden planks

across the front holding the wiring back from the

door. This does not appear to be treated

wood.



Mechanical room, that inside wiring junction box

B2DP there were two wooden planks

across the front holding the wiring back from the

door. This does not appear to be treated

wood.


staff in the smoke compartment where they are

located.

















K 017


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





19.3.6.1, 19.3.6.2.1, 19.3.6.5




Finding Include:



the elevator lobby ceiling at the door to the

restricted area are wall penetrations sealed with

different manufacturers and types of fire caulking

which are overlapping each other. This

was witnessed where there are three ¾" electrical

conduit penetrations and one penetration by a 4"

conduit with electrical cables running through it.



Pharmacy near the stairwell, approximately 8

inches above the drop ceiling are two ¾"

flex-conduits running through the rated wall




Electrical equipment room was found to have

data cable penetrating through the rated

ceiling, and the fire-rated caulking has come

loose around the data cable and is no longer

fire stopped properly.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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(X4) ID

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was observed that on the 10th floor, the Wet

Phlebotomy area over the sink area, above the

drop ceiling is a metal duct penetration which has

been fire stopped with poly sheeting and duct

tape.



Phlebotomy area above the exit door, right near

the fire damper, was found to have a gap

between the steel beam and the metal lathe and

plaster that ' s not properly fire stopped.



elevator lobby at the staff elevators, near the

double doors that corrugated cardboard has

been used to as fire stopping above the drop

ceiling.



Storage room behind the Nurses' station has the

walls not complete to the deck. There is a

fire damper going through the wall towards the

corridor side. There were also found multiple

penetrations not properly fire stopped.



the staff elevator lobby, above the double doors,

there are penetrations with three types of

fire-rated caulking overlapping each other.



Morgue area that the telephone and data

communication room has multiple penetrations


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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(X4) ID

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through the ceiling that aren't properly fire

stopped. There are about a dozen of them in

this area. Some don't have any fire-rated caulking

in them at all. Several of the others have

two different manufacturers of caulking

overlapping each other. Penetrating the overhead

is a conduit and a pipe-ducted chase that has

been fire stopped improperly using expandable

foam with fire-rated caulking over the top of that.


was observed that on the 2nd floor the

smoke doors in the staff elevator lobby, at the

separation between the East and South

buildings, there is one penetration by a 2" conduit

with data cable above the drop ceiling that has

two different manufacturers of fire-rated caulking

overlapping each other.


was observed that on the 1st floor in the

electrical equipment room a floor penetration has

two different types of fire-rated caulking

for a 3" pipe, with electrical conduit running

through it.



separation double doors at the South & West

corridor was found to have several penetrations

above the drop ceiling not properly fire stopped.


was observed that on the 14th floor, Pharmacy,

there is a hole in the ceiling tiles just outside the


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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blocked door to the lobby.


was observed that on the 14th floor, elevator

lobby, near pharmacy reception area, penetration

of wall by approximately 4" metal pipe or conduit,

that is not properly sealed.




compartments.

















K 018


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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(X4) ID

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Findings include:



nurses' station, the biohazard storage room has a

roller latch on the door.



Soiled Utility room across from the nurses' station

has a roller latch on the door.



Biohazard storage room at the nurses station was

found to have a roller latch on the door.



Biohazard Dirty Linen storage room has a roller

latch on the door. This door is not positive

latching.



Janitor's Closet behind the old Gift Shop area

does not have a rated door or a closer.


was observed that on the floor 14, Stairwell W2,

the rated door to the stairwell has a gap at the

bottom, in excess of 3/4" clearance as allowed by

1999 NFPA 80, 1-14.1 Clearance table.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG







conference room door, across from patient room

1026, will not latch.


was observed that on the 6th floor west, CVS

Physicians Assistant office, the corridor door is a

1.5 hour rated door and frame, with a magnetic

hold open device, but there is not a closer on the

door.



suite 420/421, the door will not latch. There is a

roller latch on this door.



from phlebotomy to the corridor, there is a rated

door, where the closer has been removed from

the door. This is area does not have fire sprinkler

coverage.



phlebotomy, the vertical fire door at the counter

does not operate freely.








K 020


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG








8.2.5.6. 19.3.1.1.





Findings include:



Mechanical shaft in the mechanical room, near

stairwell #1 has 2 conduits penetrating the

block wall into the rated shaft approximately 9 ft

above the floor . The penetrations were

sealed with a combination of expandable foam

and fire-rated caulking.


was observed that on the 15th floor, there is

a penetration in the mechanical room near

stairwell #1 into the small mechanical shaft by a

12" duct through the rated wall. There is no

fireproofing or fire sealant around the sleeve.



mechanical equipment room, the rated shaft

closest to the staff elevator lobby, is one

8" duct penetrating the rated shaft approximately

ten feet above the floor without proper fire

stopping around the penetration.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






mechanical equipment room, the rated shaft

closest to the staff elevator lobby above the

shaft access door, on the opposite side, was an

8" plumbing line penetration that isn't

properly sealed, approximately ten feet above the

floor.



mechanical shafts in the mechanical rooms have

three access doors that are not self closing

and latching.



Pharmacy area above the stairwell door has a

large penetration with a 1" electrical conduit

about 3 ft above the drop ceiling with most of the

block taken out without proper fire

stopping.



Main elevator lobby at the corridor elevator shaft

wall has 2 conduits penetrating the shaft

wall approximately three foot above the ceiling,

and a large opening beside a duct going into

the shaft as well not properly fire stopped.



corridor wall above the #3 stairwell door has a

penetration by a 4" pipe going through a

sleeve approximately three feet above the

dropped ceiling. The annular space between the

sleeve and the pipe is not properly fire stopped.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






Pharmacy Specialist's office, approximately 2ft

above the dropped ceiling towards the back

of the office has a 1" pipe penetration into the

elevator shaft wall that has been sealed with

expandable foam and then touched up with some

fire-rated caulking around the pipe. The

end of the pipe is open and is not sealed with fire

stop.


was observed that on the 12th floor, the old

dumbwaiter shaft is being used as a mechanical

shaft for the pneumatic tube delivery

system. The shaft walls have been breached with

entire courses of block out which have

destroyed the shaft rating. There was lumber

found in the shaft also which does not appear

to be treated wood.



Phlebotomy area in the central core has a rated

wall above the ceiling over the doorway that has

wire lathe and plaster with duct tape used to seal

up the seam at the transition from

plaster to sheetrock. This is not proper fire

stopping.



the drop ceiling across from room 1007 has a 1 ft

x 1 ft section of the 8" concrete block

missing with a bunch of electrical conduit running

through it into the rated shaft. This

penetration is not properly fire stopped.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





electrical closet at the rated shaft has a breach in

the block wall that hasn't been properly fire

stopped.



staff break room and shaft wall a breach in the

shaft wall with data cables penetrating about

a 4" opening. It has not been properly fire

stopped.


was observed that on the 7th floor, here is a

shaft wall in the back of the break room that

appears to have had a section of the block wall

removed for a 2" conduit penetrating about 6 "

into the block and not properly fire stopped.


was observed that on the 7th floor, the old

dumbwaiter shaft is being used as a mechanical

shaft for the pneumatic tube delivery

system. The shaft walls have been breached with

entire courses of block out which have

destroyed the shaft rating. There was lumber

found in the shaft also which does not appear

to be treated wood.



Morgue area, the data electrical closet that the

door going into that area is 1 ½-hour rated

door with a closer. The wall is a 2-hour rated wall.

The wall is not complete to the overhead

deck above the drop ceiling.



laboratory area that there is a rated shaft with


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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(X4) ID

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double doors. Access could not be gained

through the doors as they were found to have a

desk placed In front of them. This appears to

be a 2-hour rated mechanical shaft without proper

rated doors, hardware or closers.



Small office near the lab area the two-hour rated

wall above the doorway drop ceiling has

about a 10" X 3' tall penetration through the rated

wall. This is not properly fire stopped.



above the ceiling at the Staff Elevator lobby there

are 2 penetrations into the elevator shaft

by 3/4" conduit, approximately 18" above the

ceiling and the hole is approximately 3" in

diameter. The other is by the stairwell and is

about the same size. Neither penetration is




Mechanical Room that there are several

penetrations into the central mechanical shaft

that are not properly fire stopped.



Mechanical room, just outside of Stairwell #1, that

the central mechanical shaft does not have a

rated access door installed. It was also found

there are multiple penetration not



was observed that on the 3rd floor, both


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

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sides of both elevator doors need to have the fire

stopping completed.



back of the elevator shaft there is a large section

of the block wall missing. This needs to be

repaired or properly fire stopped.


was observed that on the 5th floor, that the

top and bottom of the elevator door frame has

openings which are not properly fire stopped.


was observed that on the 9th floor of the

Main elevator shaft, above the door of elevator #3

are openings that are not properly fire

stopped. The top of the door has sections of

block missing.


was observed that on the 4th floor, Main

elevator shaft, above elevator #6 door there is

brick that is loose and protruding into the

shaft. It needs to be secured and properly fire

stopped.



Main elevator shaft, above all 3 of the door

frames, there are openings that need to be




elevator shaft above the door of elevators #4 & 5

needs to have proper fire stopping behind

the metal plate.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






was observed that on the top of Main

Elevator shaft #2, the smoke detector conduit

comes through the block wall and is not



was observed that on the 1st floor, Main

elevator shaft, above the doors in the front wall

are 3 spots that need be properly fire stopped.


was observed that on the 15th floor, vertical shaft

near IT compartment area, unsealed penetration

in floor with fiber optic cable.


was observed that on the 14th floor storage room,

near Pharmacy, the vertical shaft to the left as

you walk in the door has a penetration by two

copper pipes with shut-off valves. This

penetration is to a rated vertical shaft, and there

is nothing sealing this penetration.


was observed that on the 6th floor west, next to

the abandoned dumb waiter, a fire rated shaft

door has been installed in the shaft, but it is not

properly sealed for any rating of the vertical shaft.


was observed that on the 6th floor, staff lounge,

across from patient room 618, there are unsealed

penetrations and open conduit to a rated vertical

shaft.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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(X4) ID

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room 505, above the drop ceiling, that there are

unsealed penetrations in the cinder block wall, left

side, where the stair tower is attached.


was observed that on the 5th floor, between

patient rooms 507 and 504, above the drop

ceiling, at the vertical shaft, there is a unsealed

opening by an oval shaped fitting, which goes into

the vertical shaft. The opening to this fitting is also

covered by an unknown material. This material

should be properly rated for the shaft.


was observed that on the 2nd floor, W1 Stairwell,

a penetration in the wall needs to be fire stopped.

There is also a piece of 3/4 electrical conduit that

is not sealed.


was observed that on the 1st floor, W2 stairwell,

there are unsealed penetrations from the stairwell

to the corridor side.



mechanical room, door to main elevator bank pit

room, there is a gap at the bottom of the door, in

excess of 3/4" clearance as allowed by 1999

NFPA 80, 1-14.1 Clearance table.



mechanical room, main elevator bank pit room,

there are unsealed penetrations to the left once

you enter the room.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

ID

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(X4) ID

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activation of:






19.2.2.2.6, 7.2.1.8.2


K 021




Findings include:



level, the Main lobby connector door at the

separation to the Parking Garage was found to

have the automatic smoke door not closing

completely and latching.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG













occupants. 7.10.1.4


K 022



Findings include:



double-doors at the expansion joint, near the

men's locker room near the CNS Parent

Educator office are shown as a horizontal exit on

the fire escape plan. There are no exit

signs on either side of the double doors between

the West building and the South building.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





the Stairwell #2 exit sign has come loose from the

wall.



staff/service elevators, the exit sign directing you

to the south tower, is not in place. This sign was

found, illuminated, above the drop ceiling.
















19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4


K 025



Findings include:



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





was observed that on the 2nd floor, corridor at

imaging 1 and 2, there is a 2 ft x 2 ft hole, in a

marked, rated smoke barrier.




compartment.














19.3.7.7


K 027



maintained.

Findings include:



Pharmacy Specialist office has a door closer on it

that has been disconnected. All of the

corridor doors appear to be smoke tight, with


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closers.



Pediatrics area storage room has a 1 ½-hour

rated door frame but the door does not have a

closer on it.


was observed that on the 11th floor, the two

storage closets across from room 1103 have no

closers on the doors.



Linen storage room across from room 1003 and

the storage room across from room 1002 do not

have closers on the doors.


was observed that on the 9th floor, the two hour

separation double doors at Stairwell 3, near room

900, the astragal is missing on one of the leaves

and it there are screw holes in the rated door.



medical supply room behind the nurses' station

had the doors open to the corridor and no

closers on them.


was observed that on the 6th floor, the door

is propped open for the Storage room at the rear

of the connector corridor across from room

604. The closer is holding it open without an

automatic release from fire alarm system

activation.


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Praxis system med storage room there are wire

racks with open combustible storage. There

are no closers on the rated doors.



storage room across from room 516 needs a door

closer on it. This room contains

combustible storage.



power level room, across from room 515, rated

door with the closer on it is not closing

completely.


was observed that on the 4th floor, the Clean

Utility room door was found blocked open with a

cart.


was observed that on the 2nd floor at the

double doors into the Patient Treatment area,

outside of Ultrasound 2 room there are 2

automatic double doors that remain open, do not

have releases, and cannot be closed. These

doors are in a smoke barrier wall.



entry lobby double glass doors do not close tightly

at the door edges to provide proper

smoke tightness when closed.


was observed that on the 5th floor, smoke barrier


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doors next to patient room 514, that the doors will

not properly close.


was observed that on the 3rd floor, main elevator

lobby, the rated smoke doors, the right door will

not latch. These doors also do not have fire rated

hardware.
















permitted. 19.3.2.1


K 029



Findings include:




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Mechanical Room, on the left near the entrance

door are four ¾" conduits penetrating

through the rated block wall approximately nine

feet above the floor and poly sheeting has

been stuffed into the hole in the block. This

penetration is not properly fire stopped.



Phlebotomy area had two rated door frames

without doors. This area is now open to the

corridors on both sides, which adds to the open

square footage of the smoke compartment.



found the Dirty Utility room across from the

nurses' station had a roller latch on the door

and it is closing completely.


was observed that on the 9th floor, the room next

to room 919, in the CTL office appears to be a

patient room renovated as an office and a storage

area. This is a change of use for this room. The

storage is not orderly and neat.


was observed that on the 3rd floor the

Morgue entry door is not a rated door. It does

have a 3-hour rated frame and it does have a

closer.


was observed that on the 3rd floor outside

the lab area in the corridor there is a storage

room without a rated door with a closer. The

combustible storage is up to the drop ceiling.


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was observed that on the 2nd floor in the

changing rooms across from X-ray #2 that Room

#5 is being used for oxygen tank storage.

There are eight tanks stored and these should be

in a proper, rated storage room.



Imaging Supply room #1, next to the Staff Lounge

does not have a rated door with a closer.

This door is in a two-hour wall.


was observed that on the 2nd floor the

storage room at the entrance to the CTI/MRI wing

at Stairwell #3 does not have a rated door with a

closer.



the Mechanical room was found that there are

multiple penetrations not properly fire stopped.



Mechanical Room that two flammable storage

cabinets were found open and not closed and

latched.


was observed that on the 15th floor, mechanical

room, There is storage in room, near AHU29,

under the ductwork.


was observed that on the 14th floor storage room,

near pharmacy, penetrations above the double

doors going up the corridor side are not sealed.


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There is also a piece of metal conduit on the

right-hand side looking toward the corridor, which

also has a penetration with some network cable

going through it, that is not sealed.


was observed that on the 11th floor, across from

patient room 1126, that door to the storage room

is obstructed by a bench, and it will not close.


was observed that on the 3rd floor, room where

the laundry chutes terminates, the rated door to

the sprinkler valve, does not latch. The door has a

pull handle attached to it.



near the automated area, a wall access panel,

door is missing from the wall access panel.


was observed that on the basement level, old

shop area, the room is being used for storage.

There is not a closer on the pair of doors from this

room to the elevator lobby.



housekeeping area, there are unsealed

penetrations from this room to the adjacent

mechanical room.



are located.




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Laboratories employing quantities of flammable,

combustible, or hazardous materials that are

considered a severe hazard are protected in

accordance with NFPA 99. (Laboratories that are

not considered to be a severe hazard meet the

provisions of K29.) Laboratories in health care

occupancies and medical and dental offices are

in accordance with NFPA 99, Standard for Health

Care Facilities. 10.5.1


K 031


maintain the protection an area of the Laboratory

considered a severe hazard.

Findings Include:



Lab area at the Specialist Manager ' s office that

the rated wall for the corridor is continued to the

entry door into the office. This doorway through

the rated wall does not appear to be a

rated door or frame, and does not have fire rated

hardware or a closer.



Lab HPV samples area that the entry door from

the corridor is not a rated door and does not

have a closer on it. None of the doors from the

corridor appear to be rated doors with


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closers to properly protect the openings into the

corridor from the lab area.


patients in the area where they are located.




Exit components (such as stairways) are

enclosed with construction having a fire

resistance rating of at least one hour, are

arranged to provide a continuous path of escape,

and provide protection against fire or smoke from

other parts of the building. 8.2.5.2, 19.3.1.1


K 033


maintain the fire resistive rating of an exit

component.

Findings Include:


was observed that on the 4th floor, W2 stairwell,

there is a 20 minute rated door installed here.

This should be a 1.5 hour rated door.







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Travel distance (exit access) to exits are in

accordance with 7.6. 19.2.5.10



ensure that the travel distances are in accordance

with the Life Safety Code.

Findings Include:


was observed that on the 1st floor, the exit

corridor and travel path that starts at the Gift

Shop has a travel distance to exit the building

in excess of the allowable 200 ft and the path

exits eventually into a parking garage.








7.1. 19.2.1


K 038




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accessible.

Findings Include:


was observed that on the ground floor, W1

stairwell, the egress directional gate is loose,

obstructing egress.










K 048




Findings Include:



Emergency procedures manual was not available

at the nurses' station. It was indicated that

the procedures were on line, they are not in

printed form, and are not available for use by the

nursing staff.




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nursing staff.







nursing staff.


was observed that on the facility records, the

facility failed to maintain written emergency

procedures manuals at the nurses stations to be

available to facility staff members.


was observed that on the 9th floor nurses station,

that a printed copy of the emergency procedures

manual was not available.










K 050


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alarms. 19.7.1.2





Findings include:


was observed that on the facility records the

fire drill documentation is not complete.








NFPA 72, National Fire Alarm Code, to provide

effective warning of fire in any part of the building.

Activation of the complete fire alarm system is by

manual fire alarm initiation, automatic detection or

extinguishing system operation. Pull stations in

patient sleeping areas may be omitted provided

that manual pull stations are within 200 feet of

nurse's stations. Pull stations are located in the

path of egress. Electronic or written records of

tests are available. A reliable second source of

K 051


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power is provided. Fire alarm systems are

maintained in accordance with NFPA 72 and

records of maintenance are kept readily available.

There is remote annunciation of the fire alarm

system to an approved central station. 19.3.4,

9.6



maintain a complete fire alarm system.

Findings include:



entry lobby has a fire alarm manual pull station

which excedes the allowable distance of 5 ft

away from the doors.











K 052


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Findings include:


was observed that on the 15th floor, the fire

alarm control panel room near the elevator lobby

has no signs indicating there is fire alarm

equipment inside.


was observed that on the 13th, 14th & 15th

floors, there is a mixture of audio/visual devices

on the floors that include bells, horn and

strobes (bells with strobes on the 13th & 15th

floors and horn/strobes on the 14th and other

floors). There are two different types of sounders

in various areas of the building which do

not generate a consistent alarm sound when

activated which can be confusing to the

occupants of the buildings traveling from area to

area. Section 9-6.3.9


was observed that on the 3rd floor in the rest

room shower in the Morgue area, storage


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appears to be blocking the fire alarm strobe

mounted on the wall.


was observed that on the facility records, the fire

alarm system periodic service, inspection and

testing records are not complete.


was observed that on the 15th floor mechanical

room, there does not appear to be any audible or

visual fire alarm devices in the room.


was observed that on the ground floor, men's

bathroom, near stairwell W2, there is no audible

or visual fire alarm device.



shop area, the heat detector, appears to be

damaged.











K 054



A. BUILDING





(X3) DATE SURVEY

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Findings include:



little kitchen area by room 402 there is a smoke

detector that is in place but does not appear

to be in service.


was observed that on the facility records it

appears the smoke detectors have not had the

required sensitivity testing conducted.



















K 056


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Findings include:


was observed that on the 15th floor, the staff

elevator lobby and near the stairway in front of the

mechanical room there are no sprinklers installed.



bathroom off from the elevator lobby near the

restricted area door does not have complete

sprinkler protection for that area.



Pharmacy receiving has the sprinkler closest to

the receiving door in the corridor by the

service staff elevators appears to be over nine

feet off from the storage divider wall. This

sprinkler does not appear to provide proper

protection due to improper spacing.


was observed that on the 14th floor, inside

the main Pharmacy are two sprinklers

approximately 9 ft off the wall and that may

exceed

the proper spacing allowed.



a closet in On-call room #11, Ped's Coverage,

which does not have a sprinkler installed in it.


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linen chute does not appear to have sprinkler

protection in the chute itself.



corridor near stairwell 3 the sprinklers are

obstructed by the surface-mounted lighting. There

were found two sprinklers in this area that are

affected.


was observed that on the 9th floor, the CTL

office has two small closets with no sprinklers

installed in either of the two offices.



Director of Orthopedics office that the sprinkler

coverage may not protect the area

completely.



computer work station alcove near room 704 has

no sprinkler protection.



no sprinkler protection the Chaplain's office,

Chaplain's office corridor, or in the bathroom

for the Chaplain's office.



no sprinkler protection in the corridor by the linen

chute in the Chaplain's office.


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was observed that on the 4th floor, in

stairwell #1 the sprinkler control and test valves in

the stairwell do not have proper signage, as

required by 1999 NFPA 13, 3-8.3.




there is a sprinkler control valve without

the proper signage to indicate what portion of the

building it controls, as required by 1999 NFPA 13,

3-8.3.


was observed that on the 1st floor the

Administrative offices by Stairwell #1 have no

sprinkler protection.


was observed that on the 1st floor outside

the elevator lobby at the double doors, entering

into the Medical Office area that there

sprinkler coverage near the elevator lobby is not

proper.



vacant area that used to be the Gift shop does

not appear to be properly sprinklered. The

sprinklers in this area do not appear to be

properly spaced and the incorrect type appears to

be in place in some areas.



ceiling at Stairwell #2 was found with a note in

marker "Grid tamper valve". It appears there

is a sprinkler control valve above the ceiling at


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this location. Proper signage is needed at

this valve to properly indicate what it controls, as




the Service Elevator Lobby does not have

sprinklers installed in this area.



the fire pump supply piping in the Mechanical

room does not appear to have the flange

bracing proper where the piping enters the

basement wall, as required by 1999 NFPA 13,

11-2.5.1.



the mechanical room fire pumps do not appear to

have the proper gauges installed on the

suction sides of the pumps, as required by 1999

NFPA 20, 2-5.2.



the mechanical room fire pumps do not appear to

have the pump bases properly filled with

grout as required, as required by 1999 NFPA 20,

3-4.1..


was observed that on the 1st floor, storage room

where crash cart is stored, there is no sprinkler

coverage.



shop area, there in no sprinkler coverage in this


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area.





Required automatic sprinkler systems have

valves supervised so that at least a local alarm

will sound when the valves are closed. NFPA

72, 9.7.2.1


K 061


supervise automatic sprinkler control valves as

required.

Findings Include:




there is a sprinkler control valve that is

not monitored electrically or secured in the open

position.

This has the potential to affect the area controlled

by the valve.





K 062


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25, 9.7.5




Findings include:



Elevator Penthouse, the gauge at the top of the

standpipe is over five years old. It appears to

be in need of the five-year service.


was observed that on the 15th floor, the low-point

drains on the pre-action system, in the elevator

equipment room and the control valves on the

pre-action system, need identification signs, as




sprinkler in front of the double doors behind the

service elevator lobby is not properly

installed. The deflector is even with the drop

ceiling and the escutcheon is missing.


was observed that on the 14th floor, outside

of the Pharmacy area, in the stairwell, the fire

system control valves do not have proper

signage, as required by 1999 NFPA 13, 3-8.3.


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was observed that on the 13th floor, the staff

elevator lobby there are quick response sprinklers

and standard response sprinklers installed. This

is a mixing of thermal sensitivity for the sprinklers

in the same area. Also, there is incomplete

sprinkler coverage near the exit door at W2

stairwell. In addition, it was found that one

sprinkler appears to be corroded in the corridor

outside of the Janitor ' s closet.



a bathroom back in the On-call sleeping areas

with the sprinkler missing the escutcheon.


was observed that on the 12th floor, in room 1214

there is one concealed type sprinkler in the main

patient room and another in the

bathroom, both of which appear to have the

covers painted over. These need to be replaced.



concealed sprinklers for the soffit's in the patient

rooms and in the bathrooms throughout the

smoke compartment have the covers painted

over and need to be replaced.


was observed that on the 12th floor, in room 1206

one concealed sprinkler is missing a cover plate.



nurses ' station, just outside the main elevator

lobby, the escutcheon is missing from one

sprinkler head.


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Director of Medical Surgery area has the soffit

system loose from the wall at two sidewall

sprinklers. The piping and/or soffit need to be

secured properly.



waiting room bathroom at Stairwell 3 the

concealed sprinkler is missing a cover plate

assembly.


was observed that on the 10th floor, one of

the horizontal sidewall sprinklers escutcheon has

come loose and is posing as

obstruction in the Clean Utility room across from

the nurses' station.


was observed that on the 9th floor, in rooms 915

and 916 there are two concealed type sprinklers

with painted covers.



throughout the 9th floor in the hard soffit areas of

the patient rooms have painted covers on

the concealed sprinklers.



bathroom outside of the Director of Orthopedics

office that the sprinkler is missing the

escutcheon.



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was observed that on the 9th floor, two

sprinklers in the corridor are obstructed by

surface-mounted light fixtures next to the

elevator lobby near the linen chute, in Stair 3.



main elevator lobby next to the nurses' station

there is one sprinkler that is obstructed by a

surface-mounted light.


was observed that on the 7th floor, the work

station behind the nurses ' station has one

sidewall sprinkler missing the escutcheon.



elevator lobby that one sprinkler appears to be

obstructed by a surface-mounted light.


was observed that on the 7th floor, stair 3,

behind the elevator lobby a sprinkler appears to

be obstructed by a surface-mounted light.



patient room 602 bathroom a concealed-typed

sprinkler cover is painted.


was observed that on the 6th floor, in room

612 that two concealed sprinkler covers were

painted, one in the bathroom and one in the

hard soffit at the entrance door.




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613 there were two painted concealed sprinkler

covers, one in the bathroom, and one in the

hard soffit ceiling in the entryway.



614 there were two painted concealed sprinkler

covers, one in the bathroom, and one in the

hard soffit ceiling in the entryway.


was observed that on the 7th floor, outside

the waiting room/rest room at stair 3, the

escutcheon is missing from a sidewall sprinkler.



patient room 520 bathroom there appears to be

some foreign material on the sprinkler in the

bathroom.



the computer work station behind the nurses'

station the sprinkler is loaded with dust.


was observed that on the 3rd floor in the rest

room shower in the Morgue area the storage is

closer to the sprinkler than the 18" minimum

clearance allowed.


was observed that on the 3rd floor, in the

rest room shower in the Morgue area, the

sprinkler is missing the escutcheon.




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elevator lobby there is a hard spline ceiling

outside of the Fire Department connection

cabinet with a concealed sprinkler with the plate

painted and stuck to the ceiling.



level in the Main entry lobby, at the Information

Desk, next to the security camera and

outside of the electrical equipment room that one

sprinkler is missing the escutcheon.



level behind the Information Desk, to the left of

the main entry lobby doors, office #2 is




Staff Elevator lobby that one sprinkler has the

concealed type sprinkler cover damaged.



the sprinkler control valves at the Staff Elevator

lobby do not have proper signage, as required by

1999 NFPA 13, 3-8.3.



the sprinkler gauges on the basement riser

appear to be dated 1968 and do not appear to

have had the required 5-year service conducted,

as required by 1999 NFPA 25, 9-2.8.1.



the Mechanical room air handler duct for unit


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

ID

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AHU16 has upright style sprinkler installed

through the side of the duct, presumably to

provide protection for the interior of the duct from

some hazard. These sprinklers are not properly

installed. The existing sprinklers were also

found to be severely corroded.



the Mechanical room sprinkler piping does not

appear to be color coded as fire protection

piping, and also there was found a low-point drain

that did not have a plug in place or proper

signage.



the fire pump control and test valves in the

Mechanical room do not have proper signage, as




the mechanical room fire pumps shaft packing

appear to be leaking excessively.



the mechanical room fire pumps check valves do

not appear to have had the required 5-year

service conducted on them, as required by 1999

NFPA 25, 9-4.2.1.



sprinkler systems have not had the required five

year service conducted.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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DEFICIENCY)

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DATE

ID

PREFIX

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standpipe systems have not had the required

periodic service and flow testing conducted.


was observed that on the west elevator machine

room, has a pre-action fire extinguishing system.

This system does not have any signage, as



was observed that on the sprinkler escutcheon is

missing in the refrigerator or frozen

pharmaceutical area, next to the Pharmacy

Manager ' s office.


was observed that on the 12th floor, multiple

patient rooms have recessed sprinkler heads,

where the heat collector has been painted.


was observed that on the 12th floor, corridor,

sidewall sprinkler heads where the deflectors are

damaged.


was observed that on the 12th floor storage room

across from patient room 1217, the escutcheon

on the sprinkler head is not properly covering the

opening in the corridor wall.


was observed that on the 12th floor, main

elevator lobby, near nurses station, the sprinkler

escutcheon is missing.


was observed that on the 12th floor, outside of


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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DEFICIENCY)

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DATE

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the Nursing Director's office and patient room

1200, near the visitors' lounge, there are two

sprinkler heads where the spray pattern would be

obstructed by the light fixtures.


was observed that on the 10th floor staff lounge,

across from patient room 1020, network cable

touching a sidewall sprinkler head. This would

obstruct the spay pattern of the sprinkler head.


was observed that on the 9th floor, patient rooms

910, 911, there are recessed sprinkler heads

where the heat collector has been painted.


was observed that on the 9th floor nurses station,

there are sidewall sprinkler heads above the

clean and dirty linen rooms, that have missing

escutcheons.


was observed that on the 7th floor, at patient

room 718, a sidewall sprinkler head on the

corridor into the room needs to be sealed where

the escutcheons meets the wall. The sprinkler

head in the bathroom also has what appears to

be drywall mud, on the collector.



622, the recessed sprinkler head has been

painted, just outside the bathroom door.



601, also marked "CS OR Storage", the recessed

sprinkler heads in the entrance and the bathroom,


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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DEFICIENCY)

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have paint on the heat collector.



rooms 420, 421, the sprinkler head near the fire

extinguisher cabinet has a missing escutcheon.


was observed that on the 2nd floor electrical

room, near Ultrasound 3, the sprinkler head



was observed that on the 2nd floor, data room in

Xray, next to Ultrasound 4, the sprinkler head is



was observed that on the ground floor, Patient

Registration Manager's office, a partition has

been constructed and there is no longer adequate

sprinkler coverage.



near the front entrance, the heat collector is

missing from recessed sprinkler head.



the sprinkler escutcheon is loose, and will not

stay up at ceiling tile.



magazine area, there are 2 sprinkler heads which

are less that 6 feet from each other.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

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DATE

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was observed that on the ground floor, gift shop

storage room, the sprinkler head is missing a

escutcheon or heat collector.








9.7.4.1. 19.3.5.6, NFPA 10


K 064



Findings Include:


was observed that on the 14th &15th floors, there

are CO2 - BC type fire extinguishers stationed in

the main corridors throughout the building. These

should be ABC Dry chemical style.


was observed that on the 6th floor. fire

extinguisher cabinet, next to room 621, has a

Carbon Dioxide Extinguisher in the cabinet. This

is the improper type of fire extinguisher for the

hazard.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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was observed that on the 5th floor, near the main

elevator bank, the fire extinguisher cabinet has a

Carbon Dioxide Extinguisher in the cabinet. This

is the improper type of fire extinguisher for the

hazard.


was observed that on the 2nd floor, main elevator

lobby, the fire extinguisher cabinet has a Carbon

Dioxide Extinguisher in the cabinet. This is the

improper type of fire extinguisher for the hazard.










19.5.2.2


K 067

Based on observations, the facility to install


specifications.

Findings Include:



mechanical room access door for fire damper

#FD15-25 was found blocked by metalic conduit


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



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DEFICIENCY)

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across from the mechanical room entrance doors.



Department Secretary ' s office is a chip board

wooden desk with laminate sides built over the

top of an electric baseboard heater. This could be

a fire hazard as the combustible material is closer

to the heating appliance than is allowed.



the Mechanical was found to have no fire or

smoke dampers for the ducts entering and

returning from the central mechanical shaft.


was observed that on the facility records, the fire

and smoke dampers have not had the periodic

service and testing and inspections

conducted.


was observed that on the 12th floor, case

managers office, modular furniture has been

installed over a electric baseboard heater. There

is visible pyrolysis damage to the furniture.



mechanical room, near where the double doors

come in at the north end of the mechanical room.

There is a penetration that has been cut in the

supply air duct that is not sealed with a fire rated

material.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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Rubbish Chutes, Incinerators and Laundry

Chutes:

(1) Any existing linen and trash chute, including

pneumatic rubbish and linen systems, that opens

directly onto any corridor is sealed by fire resistive

construction to prevent further use or is provided

with a fire door assembly having a fire protection

rating of 1 hour. All new chutes comply with

section 9.5.

(2) Any rubbish chute or linen chute, including

pneumatic rubbish and linen systems, is provided

with automatic extinguishing protection in

accordance with 9.7.

(3) Any trash chute discharges into a trash

collection room used for no other purpose and

protected in accordance with 8.4.

(4) Existing flue-fed incinerators are sealed by fire

resistive construction to prevent further use.

19.5.4, 9.5, 8.4, NFPA 82


K 071


maintain the Laundry Chute as required.

Findings include:



linen chute room door is not self closing.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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DEFICIENCY)

(X5)

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DATE

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linen chute does not appear to have sprinkler

protection in the chute itself.











7.1.10


K 072



obstructions.

Findings Include:



corridor to the left, facing the nurses ' station is

an excessive amount of equipment stored in

the corridor. There were computer carts, lifts and

other equipment that was unattended. It was all

kept to one side of the corridor, but appeared to

be stored there instead of staged for

utilization while attending patients.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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DEFICIENCY)

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corridor near room 522 has equipment storage in

the corridors on both sides of the hallway.



entry lobby double glass automatic doors do not

open for emergency use (pushing them to

swing out) due to a rug on the floor in front of

them which bunches up and stops the doors

from being opened.


was observed that on the 8th Floor West -

Nurses' Station, between rooms 813 and 812,

they have a Christmas tree that's been placed in

the corridor.









K 073




Findings Include:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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DEFICIENCY)

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DATE

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was observed that on the 11th floor, that

flammable decorations in the form of straw

scarecrows and other paper and flammable

decorations were in the main corridor outside of

the nurses ' station. Also paper decorations

were found in the visitors ' lounge on a table and

paper decorations at the nurses ' station on

the counters.



Director of Orthopedics office that a wreath made

of straw and corks from wine bottles with

loose straw hanging off the front was hanging on

the wall. This is a highly combustible

decoration.



the Mechanical room has combustibles being

stored in it close to the heating and electrical

equipment.


was observed that on the Ground Floor, Patient

Registration, near Patient Financial Assistance,

there are cloth curtains hung in this area.

Documentation needs to be provided that they

are flame resistant.



are located.





A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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DEFICIENCY)

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DATE

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99, Chapter 4.




installed properly.

Findings include:


was observed that on the facility medical

gas systems, the piping is not properly marked

throughout the facility as required.










K 103




Findings Include:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

ID

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was observed that on the 9th floor, a storage

room across from room 917 with wood furring

strips on the walls and pegboard covering three

walls from floor to ceiling. This forms wood bins

for storage of the rehabilitation trapeze

equipment. The area has sprinkler protection.





ceiling. That's in at least four locations throughout

the 9th floor.



Telephone interface room, there appears to be

birch plywood on the back of the wall that all

of the equipment is mounted onto. It does not

appear to be fire retardant wood.



data electrical room that non-fire treated wood

has been used to box-out around equipment

and as equipment mounting panels. This wood

should be fire rated.



level, the Electrical equipment closet behind the

main lobby at the Information Desk, is non

fire-treated wood used as backboards for the

telephone equipment panel mountings.



located.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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(X4) ID

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K 130



Findings Include:



the mechanical room was found to have 2

domestic cold-water backflow preventers that are

tagged for the annual inspection and testing date

of January and February 2007. This would

indicate they are overdue for the required annual

certification testing. Testing of these devices is

required by as required by 1998 NFPA 25, 7-3.8.


was observed that on the west elevator machine

room that the wall hydrant is not fully functional.

Shutoff valve is now a separate valve, not part of

wall hydrant, and is located within interior of

elevator machine room. 1999 NFPA 14, 4-3.1,

prohibits the shutoff valve between the system

and the fire department connection on the

exterior of the building.


was observed that on the upper floor, elevator

machine room for 2 bank service elevator, wall


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

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DEFICIENCY)

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DATE

ID

PREFIX

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(X4) ID

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hydrant is not fully functional. Shutoff valve is now

a separate valve, not part of wall hydrant, and is

located within interior of elevator machine room.

This is a locked room, limiting access. 1999

NFPA 14, 4-3.1, prohibits the shutoff valve

between the system and the fire department

connection on the exterior of the building.








K 147



with NFPA 70.

Findings Include:



field support office has 2 power strips

daisy-chained together under the desk and are

being

used to power the computers.



small office off the computer support area are 2

daisy-chained power strips.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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second electrical closet has a large high-voltage

electrical contactor with the cover removed,

presenting a shock hazard.



room 1204, above the drop ceiling, a high-voltage

electrical box with two knock-outs

missing on the junction box.



room 1207, that the exit sign in this area has a

knock-out missing on the electrical box.


was observed that on the 10th floor, behind

the nurses' station in the computer area there are

daisy-chained power strips supplying

power for the computers.



employee break room was found to have a

computer interface connection that has two power

wires running out through the panel box door.



the drop ceiling in the Employee break room and

electrical junction box is missing a cover

and has a wire hanging out of it.



electrical room across from room 519 electrical

panel 5B is missing a knockout cover in it.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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Praxis room has above the drop ceiling over one

of the entry doors to have one junction box

with a knockout missing, and another with a

conduit connector in it instead of a plug.



corridor above the ceiling at Stair #3 that an

electrical box is missing a knockout out of the

side of it.



storage room near the Nurses' station has

electrical panels with storage piled in front of

them closer than the 30" clearance allowed.



Communication room, is an extension cord being

used as permanent wiring powering some

of the equipment.



communications closet that a large electrical

panel door is missing.



Lab near the Director of Laboratory Service office

that there are 3 or 4 power strips which

are daisy chained together for work stations

within the center of the lab area.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

ID

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Pathology office above the drop ceiling that the

office has an electrical junction box missing

a knock-out.



laboratory area that an electrical outlet is missing

the cover plate. This is on the lower end of

the counter, near the HPV sample area, on the

right side, at the corridor wall counter.


was observed that on the 3rd floor in the lab area

by the SYSMIX CA7000 machine that and

extension cord is being used as permanent

wiring.


was observed that on the 1st floor the main

elevator lobby, above the double doors to

Conference Room C, there is one electrical

junction box with knockouts missing. It is about 6"




electrical closet outside the double doors at

Electrical panel 1B, the knockout in the

electrical panel is missing.



Strategic Development office there are two power

strips that are daisy chained together.



Staff Elevator lobby above the ceiling at the

double doors that there were 2 electrical boxes


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

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missing the covers with exposed wiring.



Mechanical room above the return air area piping

that there were a couple electrical

conduits that have separated from the electrical

junction box and the wiring is now exposed.



the Mechanical room contains the fire pump

controller and it was found the electrical wiring

junction box at the controller is missing a cover

with the wires exposed.



Mechanical room, a large electrical junction box

does not have the cover properly

secured and the wires are exposed inside. It is

located near circuit breaker E1.


was observed that on the top of Main

Elevator shaft #2, the electrical conduit for the

smoke detector is missing a conduit cover on the

elbow.



elevator shaft, there is a wire splice going into a

bus duct without a proper junction box.



415, above the ceiling, there is an open electrical

junction box at the smoke damper.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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(X4) ID

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was observed that on the 3rd floor, laboratory, at

the microbiology exit door to corridor, above the

drop ceiling, there is an open electrical junction

box.






All existing elevators, having a travel distance of

25 ft. or more above or below the level that best

serves the needs of emergency personnel for fire

fighting purposes, conform with Firefighter's

Service Requirements of ASME/ANSI A17.3,

Safety Code for Existing Elevators and

Escalators. 19.5.3, 9.4.3.2


K 160


have the elevator conform to the required

standards.

Findings Include:



Service Elevator lobby that there is a heat

detector installed instead of a smoke detector. It

is unknown if this is for shunt-trip of the power for

the elevator. There does not appear to be a recall

feature for this elevator and shunt-tripping the

power could potentially trap occupants in the

elevator car.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



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This has the potential to affect any person on this

elevator, if the detector activated.









rooms)

o The dispensers have a minimum spacing of 4 ft

from each other




an ignition source.


sprinklered. 19.3.2.7, CFR 403.744, 418.100,

460.72, 482.41, 483.70, 483.623, 485.623


K 211




Findings include:


was observed that on the 10th floor shower room

across from patient room 1026.1027, a alcohol

based hand rub dispenser is located directly


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

04 - WEST BUILDING



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

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above a electrical switch.


was observed that on the 10th floor, in patient

room 1020, a alcohol based hand rub dispenser

is located above a electrical switch.


was observed that on the 9th floor medication

room, across from patient room 902, a alcohol

based hand rub dispenser is located above a

electrical switch.






A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

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DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





Mountain Building



Sprinkler Status: Fully Sprinklered












Fire.)










K 011



between buildings.

Findings include:








A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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(X4) ID

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On 1/7/09 at approximately 1:42 pm, it was noted

that the two hour barrier wall between East and

Mountain on the 9th floor was not properly sealed

with an approved material (around 6

penetrations). Also, the gap between the doors in

this barrier is greater than that allowed by Section

2-3.1.7, NFPA 80, 1999 Edition.

On 1/8/09 at approximately 10:35 am, it was

noted that the two hour barrier in the corridor

outside of Room 897 on the 8th floor has around

4 penetrations on both sides of the wall that are

not properly sealed with an approved material and

the wall is not sealed properly at the deck. Also,

the gap at the bottom of the door exceeds the

amount allowed by Section 1-11.4, NFPA 80,

1999 Edition.


that the expansion joint did not appear to be

properly sealed outside of Room 776 on both

sides.

On 1/8/09 at approximately 2:11pm, it was noted

that the 2 hour fire barrier wall was not sealed

properly at the deck on the 8th floor.


noted that 2 hour fire barrier outside of OR1 and

OR2 between Mountain and South Buildings has

around 4 penetrations and is not sealed properly

to the deck.


noted that the two hour fire barrier between the

East and Mountain Buildings, inside the vascular

consultation room, is not constructed as a two

hour rated barrier. It appears to only have one


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

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(X4) ID

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sheet of GypBoard on either side. Also, there is a

very large penetration in the wall.


noted that the two hour barrier wall between East

and Mountain has around 4 unsealed

penetrations above the double doors in the

corridor. One area is sealed with tape. The

entire wall needs to be checked for additional

penetrations.


noted that the doors in the 2 hour fire barrier wall

were not closing and latching as required. One

leaf is dragging on the floor.




buildings.





of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4,

19.3.5.1


K 012



maintained.

Findings Include:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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(X4) ID

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that spray-on fireproofing needs to be reapplied to

structural steel members where beam clamps

have been attached or where it has been scraped

or knocked off in the penthouse of this building.

On 1/16/09 at approximately 2:12 pm, it was

noted in the linen room on the 10th floor (where

the preaction system is located), there is

structural steel missing spray-on fireproofing

material.


that there is exposed structural steel in the 2 hour

fire barrier expansion joint on the 9th floor.


noted that the 8th floor equipment storage room

has a ceiling penetration that is not properly

sealed.


noted that several beam clamps have not been

fireproofed on the 7th floor outside of Patient

Registration.

On 1/8/09 at approximately 1:02 pm, two

penetrations of the ceiling in the communication

closet near the fire barrier have not been properly

firestopped.


that there are exposed beams that have not been

fireproofed on the East side of the two hour fire

barrier on the 6th floor.


noted that fireproofing on the steel beams has

been scraped off for a hanger above the ceiling at


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

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the 2 hour fire barrier wall between Mountain and

South Pavilion.


noted that the spray-on fireproofing has been

scraped off the structural steel in the anesthesia

storage room on the 6th floor.


noted that there is an entire wall constructed of

wood in the lower portion of the mechanical room

on the 5th floor.




compartments.

















19.3.6.1, 19.3.6.2.1, 19.3.6.5

K 017


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG







ensure that corridors are separated from use

areas. The building corridors are being used as a

return air plenum requiring that the walls be

constructed as a smoke partition.

Finding Include:

On 1/6/09, 1/7/09, 1/8/09, 1/14/09, 1/15/09, on all

floors, it was observed that there are multiple

penetrations in the smoke partition walls. These

penetrations include walls that are not sealed

properly to the deck above, walls not sealed at

joints, penetrations above and around ducts,

penetrations of Med Gas piping and sprinkler

piping, and conduits. Combustible foam has

been used in some areas, mineral wool that is not

sealed, and open conduits not filled.

Examples include, but are not limited to:

Two conduits not sealed in smoke partition above

Room 1093.

Outside of Room 1081 in smoke partition, there is

a 4" penetration by conduit.

Unprotected penetration in smoke partition

outside Room 990.

In the ICU at the nurses' station on the 9th floor,

the smoke partition is not sealed properly to the

deck; also, there is a penetration to the partition

above the monitor.

ICC Room 977, 2 penetrations to the smoke

partition.

Corridor wall not properly sealed between Rooms

987 & 988.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





Two unprotected penetrations not properly sealed

between Rooms 992 & 993.

Three penetrations and damper not properly

sealed between Rooms 998 & 999.

Unprotected penetration in smoke partition

outside Room 890.

Above patient Room 891, there is a 6" hole that

needs to be repaired.

Above patient Room 885, unsealed penetrations

around the duct.

Above Room 887, there is a 6 X 6 inch

penetration through the smoke partition.

Above the Patient Registration door on the 7th

floor, there is a ¾" conduit not properly sealed.

Above the Radiologists' reading room on the 7th

floor, there is a ¾" conduit not properly sealed.

On the 7th floor, above the rest room, the wall

has been repaired and is not properly sealed.

There are cables through the smoke partition in

the women ' s locker room on the 6th floor that

are not sealed.

On the 6th floor, the equipment room has two

wire sleeves not properly sealed.

In the nurses ' station on the 6th floor, above the

PYXIS unit, there is an unsealed penetration.

The radius areas on floors 10, 9 & 8 are

constructed as smoke partitions and the smoke

partition needs to be checked from the patient

room side. During the inspection most of the

rooms were occupied, therefore, these rooms

need to be checked for penetrations, and

documentation provided to show that any

violations have been corrected.

On 1/6/09 and 1/7/09, it was noted that the

nourishment stations are open to the corridor and

are not equipped with smoke detection.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG








compartments.


















K 018




Findings include:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





On 1/6/09 - 1/7/09 between approximately 9:00

am and 4:00 pm, the following doors needed

adjustment:

Door to room 1082 is not latching



Door to room 991 has been removed








In the ICUs, many of the sliding doors were in the

breakaway position which would not allow the

doors to close and remain smoke tight.











8.2.5.6. 19.3.1.1.


K 020





A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





Findings include:

On 1/6/09, at approximately 2:24 pm, it was noted

that the stairwell on the 10th floor across from

room 1095 has at least one unprotected

penetration.


that the 2 hour rated shaft wall located in the

communications closet has around 3 unprotected

penetrations.



supply room beside the nurses' station on the

10th floor has around 2 unprotected penetrations.


that stairwell #14 on the 10th floor was not

properly sealed to the deck.

On 1/6/09, at approximately 3:45 pm it was noted

that the stairwell wall (located inside the

respiratory therapy office on the 10th floor) has an

unprotected penetration.



equipment room on the 9th floor has an

unprotected penetration.

On 1/8/09, at approximately 10:05 am, it was

noted that the 2 hour rated shaft wall located in

the equipment room on the 8th floor has around 2



that the stairway has unprotected penetrations on

the 7th floor above the lay-in ceiling.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






noted that the 2 hour shaft wall inside the

communications closet on the 6th floor has

around 2 unprotected penetrations and is not

properly sealed at the deck.

On 1/14/09, at approximately 3:05 pm, it was

noted that the 2 hour shaft walls have around 4

penetrations. The shaft liner walls are not sealed

for the entire distance of the shaft.











activation of:






19.2.2.2.6, 7.2.1.8.2

K 021


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG









Findings include:


noted that the equipment storage room door was

being held open by a wheelchair.









occupants. 7.10.1.4


K 022



Findings include:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






that the exit sign outside of angio storage room is

obstructed by a "staff only - proper apparel

required" sign.
















19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4


K 025



Findings include:


that the smoke barrier on the 10th floor at the

double doors leading into the surgical ICU

between the staff lounge and the communications

room has penetrations that are not properly

sealed. Also, two different types of firestop


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





material have been used in the same penetration.


that the smoke barrier wall that goes between the

two locker rooms appears to have had an

opening cut into it to make a pass through,

therefore, the barrier is not complete.


that there are around 3 unsealed penetrations to

the smoke barrier in the on-call senior surgery

staff bedroom.


that the smoke barrier in the equipment storage

room has penetrations sealed with two different

types of firestop material.



violation occurs and the adjoining smoke partition.














19.3.7.7

K 027


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG








maintained.

Findings include:


that the doors leading into ICU outside of the

on-call surgery are not closing properly.


noted that the gap in the doors at the ICU

conference room is too wide, Section 2-3.1.7,

NFPA 80, 1999 Edition.
















permitted. 19.3.2.1


K 029


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG








Findings include:


that the soiled utility room on the 10th floor at the

nurses' station has around 2 unprotected

penetrations.


that the additional soiled utility room on the 10th

floor has around 2 unprotected penetrations.


that the rest room door on the 10th floor outside

the visitor's lounge does not have a closer. (This

room is part of the soiled linen room).


that the linen room on the 10th floor does not

have a door closer.


that the soiled utility room on the 10th floor across

from the equipment room has around 3 unsealed

penetrations.


that the equipment storage room in the radius

area of floor 10 has around 4 unprotected

penetrations.


noted that the door to the equipment storage

room on the 10th floor does not have a closer.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





that the door to the clean linen room across from

stairwell #13 on the 9th floor needs adjustment to

latch.


that the supply room door beside the nurses'

station on the 9th floor has a gap at the top of the

door and is not smoke tight.


that the supply room on the 9th floor has around 2

penetrations that are not properly sealed.


that the supply and equipment storage room on

the 9th floor has around 2 penetrations that are

not properly sealed.


that the PYXIS storage room on the 9th floor has

around 2 unprotected penetrations.


that the door to the soiled utility room across from

room 979 needs adjustment to close and latch.

Also, there are around 3 unprotected penetrations

in this room.


that the linen closet door on the 8th floor does not

have a closer.


that the soiled utility room on the 8th floor outside

the nurses' station has around 2 unprotected

penetrations.


that the supply room across from stair #13 on the


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





8th floor has around 2 penetrations.


noted that the supply room on the 8th floor was

not smoke tight as it is not sealed at the corner.


noted that the soiled utility room across from

room 879 has around 2 unprotected penetrations.


that the angio supply room is not completely

smoke tight due to around 2 unprotected

penetrations and a portion of the wall has not

been completed.


that the soiled utility room across from the

angiograph holding area has around 3



noted that the storage room on the 6th floor has

around 2 unprotected penetrations.


noted that the equipment storage room on the 6th

floor has around 5 unprotected penetrations.


noted that the door to the soiled utility room

outside of OR #3 does not have a closer.

On 1/14/09, at approximately 10:27am, it was

noted that the supply room across from OR #3

has 3 unprotected penetrations. Some

penetrations have been sealed with combustible

foam and/or masking tape.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





On 1/14/09, at approximately 2:00 pm. it was

noted that patient rooms 638 and 633 have areas

curtained off and are being used as combustible

storage rooms. These areas are not properly

protected.


noted that the room labeled "prep room #1" and

"prep room #2" has been converted to a storage

room and is not properly protected.



are located.













alarms. 19.7.1.2


K 050




Findings include:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





Fire drills are not being conducted by sounding

the fire alarm system, only by announcements.























9.6


K 051



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






system.

Findings include:


that the elevator penthouse did not have an alarm

notification device as required by Section 9.6.3.2.













K 052




Findings include:

The fire alarm system is being tested; however,


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





the report does not conform to requirements set

forth in NFPA 72.











K 054




Findings include:

Smoke detectors are not being tested for

sensitivity rating as required. Also, the report is

not in an acceptable format as required by NFPA

72.









K 056


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG


















Findings include:


noted that there is inadequate sprinkler coverage

in the mechanical room on the 5th floor. Also,

there are places in the vertical shaft that

sprinklers are placed improperly.

On 1/7/09, at various times, it was noted that

there is insufficient sprinkler coverage on the 7th

floor in the patient areas (in what would be the

radius area) in excess of the maximum allowable

distance from the wall.






K 062


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG








25, 9.7.5




Findings include:

No documentation was provided to show that the

system had been inspected since 10/18/08.


that escutcheons were missing from sprinklers in

rooms 1096 and 1097.


that the escutcheon was missing from the

sprinkler in the restroom behind the on-call

surgery room.


that the cap is missing from the standpipe in the

10th floor stairwell. Also, the valve is not marked

to indicate which part of the system it will shut

down.


noted that the cap for the standpipe is missing in

stairwell #14 on the 8th floor.

On 1/6/09 - 1/14/09 it was noted that sprinkler

valves in the stairwells are not properly labeled.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





noted that in the sub-sterile OR #2, the sprinkler

has paint on the glass bulb.


noted that on the 6th floor, stairwell #14, the cap

is missing from the standpipe.

On 1/14/09, at approximately 2:30 pm, 5th floor

exit discharge, sprinklers in this area are

corroded.










19.5.2.2


K 067



specifications.

Findings Include:

The corridor is being used as a return air plenum.

Documentation needs to be provided from a

qualified firm or person that the locations of the

fire and/or smoke dampers are installed as


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





required in accordance with NFPA 90A and NFPA

101.

Documentation needs to be provided from a

qualified firm or person that the installed dampers

are being tested in accordance with NFPA 90A.

On 1/6/09 and 1/7/09, at various times, it was

noted that there is an electrical outlet in the

plenum outside of rooms 1085,1095, 996, 980,

888, 887, 895, 896,and at the crash cart in the

corridor at the nurses' station, with wiring

connecting a wireless router that is not rated for

plenum use.

On 1/6/09, 1/7/09, and 1/8/09 at various times it

was noted that where signs have been hung on

the 10th, 9th, 8th & 7th floors, the signs have

been mounted to wood placed above the lay-in

ceiling.


that plastic was draped in the plenum ceiling in

the angio supply room on the 8th floor.


that there is no access to the smoke damper

above room 775.









K 072


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG







7.1.10




obstructions.

Findings Include:


that a chair is being stored in stairwell #14, 10th

floor.


that egress is partially obstructed in the two

offices at the end of the hall outside of stairwell

#13 on the 9th floor.


that the end of the "radius" area on the 7th floor is

being used for storage.


that the corridor outside the angio holding area is



that the refrigerator stored in the corridor outside

of room 772 reduces the 8' required width to 7'.

Also, there are linen carts being stored in the

corridor.

Between 1/6/09 and 1/14/09, it was noted that

curtains are being hung in the ICU patient rooms


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





that extend across the egress door and obstruct

the exit.


noted that egress from the women's lounge was

obstructed on the 6th floor.


noted that the corridor is being used for storage

on the 6th floor.


noted that the horizontal exit on the 6th floor is

obstructed by storage in the corridor such that a

bed could not be rolled through this area.


noted that there are bike locks on the landing of

stairwell #14. Bikes are not permitted to be

stored in this area.


noted that the exit door from stairwell 14 at the

5th floor exit to grade was locked and would not

open in a timely manner - the magnetic locking

device was not functioning properly.


patients in the affected areas.




Soiled linen or trash collection receptacles do not

exceed 32 gal (121 L) in capacity. The average

density of container capacity in a room or space

does not exceed .5 gal/sq ft (20.4 L/sq m). A

capacity of 32 gal (121 L) is not exceeded within

K 075


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





any 64 sq ft (5.9-sq m) area. Mobile soiled linen

or trash collection receptacles with capacities

greater than 32 gal (121 L) are located in a room

protected as a hazardous area when not

attended. 19.7.5.5



facility failed to store trash collection receptacles

in a protected room.

Findings include:


noted that two large trash collection bins were

being stored in the corridor outside of the soiled

utility closet.


staff and patients in the smoke compartment.





99, Chapter 4.


K 077



installed properly.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





Findings include:

On 1/14/09, at approximately 3:07 pm it was

noted that identification of the med gas piping

system is improperly identified in accordance with

NFPA 99, 1999 Edition, Section 4-3.1.2.14.









K 147



with NFPA 70.

Findings Include:


that an unapproved extension cord was being

used for permanent wiring in the elevator

penthouse.


that the electrical panel 7EXHB inside the

angiograph room #1 has an open space.


noted that there is a junction box without an

approved cover in the ceiling across from the


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





office and equipment room.


noted that in OR #1 and OR #2 there is open

wiring behind the clocks.











rooms)


from each other




an ignition source.


sprinklered. 19.3.2.7, CFR 403.744, 418.100,

460.72, 482.41, 483.70, 483.623, 485.623


K 211




Findings include:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

02 - MOUNTAIN



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





Alcohol based hand rub dispensers are

improperly installed over or adjacent to an ignition

source throughout the building.






A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________

01 - SOUTH TOWER, LOWER 9 FLOORS



490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





South Building, Existing



Sprinkler Status: Sprinklered






the LSC 2000 Existing regulations.

The facility was not in compliance with the

Requirements for Participation Medicare and

Medicaid. The findings that follow demonstrate



Fire.)










K 011



between buildings.

Findings include:








A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






was observed that on the 7th floor, the corner of

the 2 hour fire barrier, inside the office across

from the electrical room, is not sealed to the deck.


was observed that on the 8th floor, the 2 hour fire

barrier is not sealed to the deck in the electrical

closet and at the rear exit.



barrier in the electrical closet has unprotected

penetrations.



barrier at the rear exit is not sealed to the deck.



barrier in the back of the Housekeeping closet is

not sealed to the deck.



barrier in the Employee Health storage room is



was observed that on the 5th floor at the 2 hour

fire barrier between the South to East corridor,

the wall above doors through the access hole is

not sealed at the decking.


was observed that on the 5th floor, at the double

exit doors in the 2 hour fire barrier leading from


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





South into West, one leaf of the fire doors will not

latch.


was observed that on the 5th floor in the South to

East corridor, at the door to the East mechanical

room, the 2 hour fire barrier doors are not rated,

there are unprotected penetrations and the barrier

wall is not sealed at the deck.


was observed that on the 5th floor above the

double doors leading into West, the 2 hour fire

barrier is not sealed to the deck. This occurs on

both sides of the fire barrier.


was observed that on the 5th floor, inside the

office at the 2 hour fire barrier, the barrier is not

sealed at the corner.


was observed that on the 5th floor corridor

between South and East, the 2-hour fire barrier

wall is not properly sealed to the deck.


was observed that on the 3rd floor near Stairwell

#2, the 2 hour fire barrier is not sealed to the

deck.


was observed that on the 3rd floor, at the back

wall in the electrical room, the 2 hour fire barrier is



was observed that on the 3rd floor in the South to

East corridor, the 2-hour fire barrier has


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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unprotected penetrations and is constructed with

a 1 hour fire rating.


was observed that on the 3rd floor, inside the

Housekeeping storage room, the 2 hour fire

barrier is not sealed to the deck and there are

unprotected penetrations at the expansion joint.


was observed that on the 3rd floor in the 2 hour

fire barrier at the blood bank, the door is not rated

and has no door closer.


was observed that on the 3rd floor outside of the

equipment room, there are unprotected

penetrations to the 2 hour fire barrier.


was observed that on the 3rd floor, one leaf of the

fire doors in the 2 hour fire barrier is not latching.


was observed that on the 3rd floor, in the 2 hour

fire barrier between South and East, the double

doors that go into the East mechanical room were

disabled to stay open.


was observed that on the 3rd floor inside the

Central Services Unit Director Team Leader ' s

office, there are unprotected penetrations to the

2-hour fire barrier.


was observed that on the 3rd floor, one leaf of the

doors leading into the back of the kitchen in the 2

hour fire barrier will not latch.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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TAG

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was observed that on the 2nd floor, the 2 hour fire

barrier in the back of the electrical closet inside

the office at the rear of the building is not sealed

to the deck.


was observed that on the 2nd floor, the 2 hour fire

barrier in the wall of the office has several

unprotected penetrations and the wall is not

sealed to the deck.


was observed that on the 2nd floor, in the 2 hour

fire barrier, there are approximately 7

penetrations that are not sealed.


was observed that on the 2nd floor, at the back of

the data closet, there are approximately 4

penetrations in the 2 hour fire barrier.


was observed that on the 2nd floor, at the double

doors to the two hour fire barrier, the wall is not

sealed to the deck and there are approximately 6



was observed that on the 2nd floor, there are

approximately 2 unsealed penetrations to the 2

hour fire barrier in the small conference room.


was observed that on the 2nd floor in the Medical

Auditor ' s room, the 2-hour fire barrier is not

sealed to the deck.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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was observed that on the 2nd floor at the CT MRI

waiting area, the barrier door from East to South,

is not latching.


was observed that on the 2nd floor in the 2 hour

fire barrier at the MRI waiting room, a fire damper

was activated and did not fully close. It is also not

sealed at the deck.


was observed that on the 2nd floor around the

corner from the MRI waiting room in an office, the

door in the 2-hour fire barrier is not rated.



corner from the MRI waiting room in an office, the

2-hour fire barrier is constructed with a 1 hour

rating.


was observed that on the 1st floor at the 2 hour

fire barrier, there is combustible foam sealing

penetrations.


was observed that on the 1st floor, at the 2 hour

barrier in the electrical room, data cable and

conduit are not properly sealed.


was observed that on the 1st floor, the 2 hour fire

barrier in the back of the office is not complete.


was observed that on the 1st floor, at the 2 hour

fire barrier, approximately 10 penetrations are not


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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protected and the wall is not sealed to the deck.


was observed that on the 1st floor, the doors in

the 2 hour barrier at the mechanical room are

45-minute rated.


was observed that on the 1st floor, the 2 hour fire

barrier is not sealed properly to the deck. There

are penetrations (approximately 14) not

firestopped. Combustible foam has been used to

seal some of the openings.


was observed that on the 1st floor, in the atrium

at double doors, the 2 hour fire barrier is only

constructed with 1 sheet of fire rated gypsum.


was observed that on the ground floor in the

atrium at the 2-hour fire barrier between South

and West, the doors are not rated and do not

latch.


was observed that on the the ground floor, the 2

hour fire barrier for separation of South and West

Buildings is not complete.



atrium at the 2 hour fire barrier between South

and West, there are unprotected penetrations and

it is not sealed at the deck.


was observed that on the 6th floor in 2 hour

horizontal exit corridor between cath lab and


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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mountain, the doors do not latch.


was observed that on the 4th floor across from

equipment room 1, the doors have a gap between

them that exceeds 1/8 inch and the gap on the

bottom of the doors exceed 1 inch. 1999 NFPA

80 section: 1-11.4 and 2-3.1.7. These doors also

have changed location and the barrier is

constructed with only 1 sheet of fire rated

gypsum.



equipment room 1, there are unprotected

penetrations to the 2-hour fire barrier.


was observed that on the 4th floor in the soiled

utility room on the back side of the six-bank

elevators, the 2 hour fire barrier is not sealed to

the deck.


was observed that on the 4th floor in the office

outside of 6 bank elevator, there is a

communicating opening in the 2 hour fire barrier

that is not located in the corridor.


was observed that on the 4th floor at the 2 hour

fire barrier in South to East corridor, the doors are

not latching.


was observed that on the 4th floor at the 2-hour

fire barrier above the doors, there are unprotected

penetrations and it is not sealed to the deck.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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East corridor at the East Building, the 2 hour fire

barrier is only constructed with 1 sheet of fire

rated gypsum.


was observed that on the 4th floor in the break

room, the 2-hour fire barrier is not complete on

the left side of the beam.



East Corridor at the Endoscopic lounge, there are



was observed that on the 4th floor, South to East

Corridor, at the double doors to Endoscopy, there

are unprotected penetrations and the door does

not latch.


was observed that on the 4th floor in corridor from

South to East at the East mechanical room, the

wall is not sealed to the deck and there are




East corridor at the East mechanical room, the

doors are not rated.




2-hour fire barrier has unprotected penetrations.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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2-hour fire barrier is labeled and constructed with

a 1 hour rating.


was observed that on the 4th floor at the 2-hour

barrier doors outside of OR Manager ' s office,

the double doors do not latch.




buildings.





of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4,

19.3.5.1


K 012



maintained.

Findings Include:


was observed that on the 7th floor in the corridor

leading to West, fireproofing has been knocked

off the structural beam at the 2 hour fire barrier in

several places.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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was observed that on the 7th floor, mineral wool

is exposed in the expansion joint on both sides.


was observed that on the 7th floor, a penetration

through the floor/ceiling assembly is not sealed in

the data closet.


was observed that on the 6th floor at the radius

nurses' station, there is plywood attached to the

roof deck over the bulkhead.



equipment storage room, there are 3 ceiling

penetrations that are not sealed. In addition,

there is wood being used around the pipe.


was observed that on the 6th floor in the clean

utility room in the radius, there is wood attached

to the concrete deck and there are unprotected

penetrations to the concrete deck.


was observed that on the 6th floor, women's

locker room, spray-on fireproofing has been

knocked off of beam clamps and beams. This

area is above the new restroom inside the locker

room.


was observed that on the 6th floor where the

corridor leads to the large storage room and

elevators, insulation is not sealed above the

column. The same area has a floor/ceiling

assembly that has an unprotected penetration by


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

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a pipe.


was observed that on the 6th floor, outside the

new elevators, spray-on fireproofing has been

knocked off beam clamps on the structural steel.


was observed that on the 6th floor, in the large

shell space, spray-on fireproofing has been

knocked off structural steel.



spray-on fireproofing has been knocked off

structural beams.



Housekeeping closet, PVC pipe penetrates the

floor/ceiling assembly and is not sealed.



double doors leading into West, spray-on

fireproofing has been knocked off structural

beams.



East corridor at the corner, the expansion joint is

not sealed.


was observed that on the 5th floor outside of the

elevator and mechanical room, the entire corridor

has bare structural steel and the expansion joint

is not properly sealed.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






was observed that on the 5th floor, inside the data

closet outside of the electrical room, there are

penetrations in the floor/ceiling assembly that are

not sealed.


was observed that on the 5th floor mechanical

room, there are unprotected penetrations to the

floor/ceiling assembly.


was observed that on the 5th floor inside the

mechanical room, there are multiple places that

plywood is attached to the deck. There are also

penetrations to the deck that are sealed with

combustible foam.



expansion joint and the crossover in the back of

the mechanical room, there is plastic in the

expansion joint.



#2, spray-on fireproofing has been knocked off

structural steel.


was observed that on the 3rd floor, electrical

room, spray-on fireproofing has been knocked off

structural steel.


was observed that on the 3rd floor outside of

elevators, there is exposed structural steel.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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(X4) ID

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was observed that on the 3rd floor women's

locker room, a 4" line penetrates the floor/ceiling

assembly and is not sealed.



materials manager of surgical services office,

there are unprotected penetrations to the deck.


was observed that on the 3rd floor in Materials

Management, there are unprotected penetrations

to the deck.


was observed that on the 3rd floor data closet

there is a penetration of the floor/ceiling assembly

not sealed.


was observed that on the 3rd floor data closet

located at the back of the elevator lobby, there is

an unprotected penetration of wires extending

through the floor/ceiling assembly. Also, a

penetration has been repaired with untreated

wood.


was observed that in the 5th floor mechanical

room, in some areas the spray-on fireproofing

has been knocked off beam clamps on structural

steel.


was observed that on the 3rd floor, in the data

room there are unprotected beam clamps over

the freezer area.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

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was observed that in the 3rd floor data closet has

a pipe penetrating the floor/ceiling assembly that

is not sealed.


was observed that on the 3rd floor food prep

area, conduit penetrates the floor/ceiling

assembly and is not sealed.


was observed that on the 2nd floor, there is

unprotected structural steel in the office that is

part of the 2 hour fire barrier.



double doors leading to West Building, there are

unprotected beam clamps on structural steel.


was observed that on the 2nd floor in the smoke

barrier wall at ER Bays 40, 41 and 42, the

bulkhead with numbers and nurse call lights is

made out of wood. There is also a bulkhead to

the back of the patient bays that is attached to the

deck with wood.


was observed that on the 2nd floor in the pit of

the Emergency Department, there is exposed

structural steel.


was observed that on the 2nd floor inside the data

room, outside double elevators at the Emergency

Department, there is an unprotected penetration

to the deck.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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(X4) ID

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was observed that on the 2nd floor in peds room

20, the fireproofing was scraped off the structural

steel beams for clamps and other attachments.


was observed that on the 2nd floor In the

Pediatric Emergency Department, the fireproofing

was scraped off from the structural steel beams

for clamps and other attachments.



Pediatric Emergency Department soiled utility

room, there is exposed structural steel.


was observed that on the 1st floor, the expansion

joint near the Mechanical room is not sealed.


was observed that on the 1st floor the large

Mechanical room has approximately 5

penetrations to the floor/ceiling assembly which

are not sealed.


was observed that on the 1st floor in the back of

the Electrical/Mechanical room, there is

Styrofoam 2 inches thick that runs the entire

length of a structural beam.



Electrical/Mechanical room, there are two 5 inch

EMT pipes that were core drilled through a

reinforced structural concrete beam. The core drill

is about 6 inches by 14 inches, and it is drilled

through the entire beam and steel rebar, about

three inches from the top.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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TAG

(X4) ID

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TAG






was observed that on the 1st floor inside the

resident lounge, there are unprotected

penetrations to the deck.


was observed that on the 1st floor, near stairwell

#6, there is an unprotected penetration of the

floor/ceiling assembly.


was observed that on the 1st floor, the expansion

joint above the lay-in ceiling of the small

Housekeeping Closet is not complete.


was observed that on the 1st floor in the Quality

Management Office, there are unprotected

penetrations to the deck.


was observed that on the 1st floor, in the corridor

outside the transportation elevators, the

expansion joint is not sealed.



Administrative Secretary's office, a closet was

recently constructed using combustible material.


was observed that on the ground floor at ER

parking lot, there is an unprotected penetration to

the deck above low-clearance spaces.


was observed that on the ground floor, wood has

been used to patch the ceiling.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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TAG

(X4) ID

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TAG






was observed that on the ground floor in the ER

parking, there is a space of about 6 inches filled

with Styrofoam.


was observed that on the ground floor, there are

penetrations to the two-hour wall leading to the

parking garage from the left-hand side of the

Coffee Shop. NFPA 101, 19.1.2.1


was observed that on the ground floor, the entire

two-hour wall running the back side of the Coffee

Shop is not sealed at the deck.


was observed that on the ground floor, there is

wood in the construction of the wall at the back

side of the elevator shaft.


was observed that in the ground floor

underground parking garage mechanical room,

combustible foam has been used as firestopping

in the floor/ceiling assembly penetrations.


was observed that on the 4th floor in Equipment

Storage room N2, there is exposed structural

steel.



Environmental Services storage room beside

room N2, there is exposed structural steel and

unprotected penetrations to the deck.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






was observed that on the 4th floor in the smoke

barrier wall at the computer room outside double

doors to the operating room, there are

unprotected penetrations to the deck.


was observed that on the 4th floor in the elevator

lobby, there is exposed structural steel.


was observed that on the 4th floor the entire

South to East corridor, there is exposed structural

steel where the fireproofing was scraped off.


was observed that on the 4th floor outside of OR

Director ' s and OR Manager ' s office, there is

exposed structural steel.



Anesthesia Ready Room, there is an unprotected

penetration to the ceiling deck.


was observed that on the 4th floor in the two-hour

shaft that is beside CTL Office, there is exposed

structural steel and the expansion joint is not

sealed.




compartments.





A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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(X4) ID

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19.3.3.2




Findings Include:


was observed that on the 1st floor Mechanical

Room, documentation needs to be provided to

show that the soundproofing used on the wall is

noncombustible.



where they are located.








K 017


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

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19.3.6.1, 19.3.6.2.1, 19.3.6.5




Finding Include:


was observed that on the 7th floor, the smoke

partition is not properly sealed to the deck on the

left side where it turns to go down the cross

corridor hallway at the traffic control doors. There

are also three conduit penetrations that are not

properly sealed.



partition in the Information Area on the 7th floor

has penetrations to the back wall.

Also, the partition is not sealed above the ducts.

There are 2 conduits not sealed and it is not

sealed to the deck.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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(X4) ID

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TAG







ceiling of the Staff Only Pantry, there are

approximately 15 conduits penetrating the smoke

partition that are not properly sealed.



the nurses' station there are several penetrations

to the smoke partition that are not sealed.


was observed that on the 7th floor, above and to

the left of Room 736, the duct is not sealed.


was observed that on the 7th floor, conduit is not

sealed above the sign at Room 736.



entrance to the radius, a sprinkler pipe penetrates

the smoke partition and is not sealed.


was observed that on the 7th floor, where the

smoke partition turns and goes back through the

nurses' station, it is not sealed to the deck.


was observed that on the 6th floor radius above

Room 9, three penetrations are not sealed.


was observed that on the 6th floor radius, a

domestic water line penetrates the smoke

partition and is not sealed above Room 8.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





was observed that on the 6th floor in the radius

above room 2, there are unprotected penetrations

in the corridor wall.


was observed that on the 6th floor in the radius

nurses' station above the sink, there are

unprotected penetrations in the smoke partition.


was observed that on the 6th floor at room 1 in

the radius, there are unprotected penetrations.


was observed that on the 6th floor outside the

Unit Director of CSICU Office, there is

combustible foam sealant in the smoke partition.


was observed that on the 6th floor radius, the

Doctors' Dictation Area, there are approximately 5

penetrations to the smoke partition that are not

properly sealed. Also, conduit penetrates the

drywall and is not properly sealed.


was observed that on the 6th floor elevator lobby

right before the very large shell storage room,

penetrations by conduits are not sealed with an

approved material.


was observed that on the 6th floor, outside of the

new elevators, there are unprotected penetrations

to the smoke partition.


was observed that on the 5th floor, across from

the Employee Health Storage Room, there are


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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TAG

(X4) ID

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TAG





penetrations to the smoke partition that have not

been sealed.



penetration above Employee Health Services is

not sealed.



rest room, there are 3 penetrations of conduit that

are not properly sealed.



partition above the Data Closet door has



was observed that on the 3rd floor outside the

CRT Storage Room, there are unprotected

penetrations to the smoke partition.


was observed that on the 3rd floor, above the

Chair of Surgery Office, conduit has not been

sealed in the smoke partition.


was observed that on the 3rd floor at the women's

restroom, sprinkler pipe has not been sealed with

an approved material. The men's restroom has 2

penetrations that have not been sealed. These

are part of the smoke partition.


was observed that on the 3rd floor, Vending Area,

there has been a hole cut out of the smoke

partition and is not been smoke tight.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG






was observed that on the 3rd floor Women's

Locker Room, there are conduit penetrations in

the front smoke partition that are not sealed.


was observed that on the 3rd floor, across from

the Vending Area there is a very large hole that

has been cut into the smoke partition (behind the

pipe) that has not been sealed.


was observed that on the 3rd floor at the vending

area across from the consultation room, there is a

large penetration cut into the smoke partition

above the ceiling in the back wall that is not

sealed.


was observed that on the 3rd floor, in the corner

at the exit from the Mountain View Café, there is

a 4 X 2 hole that has not been sealed. The

corner of the partition is not patched to make it

smoke tight.


was observed that on the 3rd floor, two

penetrations are not properly sealed in the smoke

partition across from the Food Services

Manager's Office.


was observed that on the 3rd floor outside of OR

Material Management, there are unprotected





A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





Materials Manager of Surgical Services Office,

there are unprotected penetrations and the wall is




Central Services Unit Director Team Leader ' s

Office, there are unprotected penetrations to the

smoke partition.


was observed that on the 3rd floor at the

Electrical Room, there are penetrations by pipes

in the smoke partition.


was observed that on the 3rd floor, kitchen prep

area, inside the door leading to the cafeteria,

there are penetrations to the smoke partition

above the sink.



door that leads into the CT/MRI Waiting Room,

there are approximately 5 penetrations in the

smoke partition that goes around this room.


was observed that on the 2nd floor, Electrical

Room, there is a penetration by conduit that is not

properly sealed.



Medical Director of Radiology, there are 2

penetrations in the smoke partition by the door.


was observed that on the 2nd floor, duct work and


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





conduits are not properly sealed in the corridor

leading toward the Emergency Department close

to the Fire Department connection.



door entering into a suite, there are penetrations



was observed that on the 2nd floor, Room 210,

the domestic water supply piping is not sealed in

the smoke partition.


was observed that on the 2nd floor, near the exit

sign leading towards the Emergency Department,

the smoke partition is not sealed at the deck.



door to the Employee Locker Room, there is a

large penetration to the smoke partition.


was observed that on the 2nd floor, above Peds

#21, there are 4 penetrations in the smoke

partition. The length of the wall needs to be

checked for any further penetrations that have not

been sealed.


was observed that on the 2nd floor in Pediatric

ER Room 20, there are unprotected penetrations

in the corridor wall.



ER Room 27, the smoke partition is not sealed to


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





the deck.


was observed that on the 2nd floor, ER outside of

Main 14, there is a penetration by a water line in

the smoke partition that is not sealed.


was observed that on the 2nd floor, at the nurse's

station in the ER, penetrations have been sealed

with red expandable combustible foam.


was observed that on the 2nd floor, close to

Triage 2, above the ceiling there are data cables

penetrating the smoke partition that are not

sealed.


was observed that on the 2nd floor, outside of CT

control room #3, copper pipes penetrate the

smoke partition wall and are not sealed. Also, the

meeting edges of the partition are not sealed.


was observed that on the 2nd floor at the CT MRI

Waiting Room, there are unprotected

penetrations in the smoke partition.


was observed that on the 2nd floor CT MRI

Registration Room, penetrations by pipes and

wires in the smoke partition are not sealed.



Electrical Room, there is an unprotected

penetration to the smoke partition above the

audio/visual device.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

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DATE

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doors at bed storage in the maintenance area,

there are unprotected penetrations in the smoke

partition and is not sealed to the deck.



Elevator Equipment Room, the smoke partition is

not sealed at the deck.


was observed that on the 1st floor in the new

electrical room of at the maintenance shop, the

wall is not sealed at the deck and there are




Mechanical Room across from Engineering, there

are unprotected penetrations in the smoke

partition and the wall is not sealed to the deck.


was observed that on the 1st floor across from

the Elevator Equipment Room in outside of

Engineering, there are unprotected penetrations



was observed that on the 1st floor at the double

doors out of the maintenance area that leads in

towards conference room D, there are



was observed that on the 1st floor, above CI

Coding in the smoke partition there is a sprinkler


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

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line and a conduit not sealed.


was observed that on the 1st floor corridor

outside the back of Medical Records, there are

approximately 20 penetrations that are not sealed



was observed that on the 1st floor in the coding

hallway, the entire length of both sides are not

sealed at the deck.


was observed that on the 1st floor, penetration

over the double doors to the Resident's Room

close to the Mechanical Room is sealed with

combustible foam.


was observed that on the 1st floor in the hallway

of the coding offices at the end, there are



was observed that on the 1st floor the hallway

entrance to the Coder, there are unprotected



was observed that on the 1st floor in the corridor

at Quality Management, there are unprotected



was observed that on the 1st floor, there are 2

penetrations of the smoke partition above the

Infection Control Practitioner's door.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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was observed that on the 1st floor, approximately

3 conduits are not properly sealed in the

communications closet in the elevator lobby.


was observed that on the 1st floor outside of

Conference Room D, there are unprotected



was observed that on the 1st floor above doors to

Conference Room D, there are unprotected



was observed that on the 1st floor, the smoke

partition above the doors for the elevators lobby,

there are 2 penetrations that are not sealed.


was observed that on the 1st floor, above the

men's and women's restrooms there are data

cable penetrations and one large hole in the

smoke partition.


was observed that on the 1st floor, smoke

partition is not sealed properly to the deck.


was observed that on the 1st floor in the alcove to

the Office of Professional Staff, there are



was observed that on the 1st floor in the corner of

the Office of the Professional Staff, there are



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

ID

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(X4) ID

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the Department of Emergency Medicine Office,

there are unprotected penetrations in the smoke

partition.



the Medical Staff Services Office, there are



was observed that on the 1st floor there are two

penetrations at the top of the atrium near the door

leading to the Board Room area in the smoke

partition that are not sealed with an approved

material.



Conference Room F at the fire department

connection, there are unprotected penetrations in



was observed that on the 1st floor above the Prep

Kitchen - Staff Only in the Board Room area there

is a penetration above the door that is not

properly sealed.


was observed that on the 1st floor in the Board

Room hallway, a hole has been sealed with a

piece of sheet rock, however, it has not been

rendered smoke tight.


was observed that on the 1st floor above


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

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DEFICIENCY)

(X5)

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DATE

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Conference Room E door, there are unprotected



was observed that on the 1st floor in the double

doors to the back side of the large Conference

Room, there are unprotected penetrations in the

smoke partition.


was observed that on the ground floor, the smoke

partition (near the escalator room) has

approximately 6 penetrations that are not sealed.


was observed that on the ground floor above the

women's room at the coffee shop, there are




Profusion Storage Room, the smoke partition is




on the side of OR 18, there are unprotected



was observed that on the 4th floor in OR 23, there

is an unprotected penetration to the smoke

partition.


was observed that on the 4th floor in the Electrical

Room beside the six-bank elevators, there are



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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TAG

(X4) ID

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was observed that on the 4th floor at the six-bank

elevator lobby, there are unprotected penetrations



was observed that on the 4th floor beside the

elevator, the smoke partition is not complete at

the OR.


was observed that on the 4th floor on the OR

Director / OR Manager ' s Office, there are

unprotected penetrations in the smoke partition

and it is not sealed to the deck.


was observed that on the 4th floor outside of Unit

Director of OR services Office, there are


some with combustible foam.



Unit Director of OR Services Office, there are


and it is not sealed to the deck.



PAPA/PACU Unit Director Office, there are

unprotected penetrations to the smoke partition.



event board, there are unprotected penetrations




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

ID

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men's restroom outside the PACU, there are




outside the Anesthesia Work Room, there is an

unprotected penetration to the smoke partition.



outside of medical director of anesthesia, a

portion of the smoke partition is missing. There

are also multiple pieces of conduit that are not

sealed.


was observed that on the 4th floor at the double

doors going into the Pre-Anesthetic Prep Area,

the smoke partition wall is not complete to the left

and there are unprotected penetrations to the

right.



Pharmacy, there is an unprotected penetration to





compartments.






K 018


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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Findings include:


was observed that on the 6th floor in the radius,

most of the sliding glass corridor doors are not

latched to the tracks.


was observed that on the 1st floor in Conference

Room E, the door is propped open.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

ID

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Mechanical Room, the corridor door is not

shutting completely and latching.


was observed that on the 3rd floor, the corridor

doors to the CRT Storage Room and

Environmental Services were modified.



Pediatric ER Rooms 17-21, 22, 23, 26, 18, 19, 20,

the sliding glass corridor doors are not latched to

the tracks.











8.2.5.6. 19.3.1.1.


K 020




Findings include:


was observed that on the 7th floor, the rated wall


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

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DATE

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behind the elevator shaft across from the

Housekeeping Room is not sealed at the corner.

This same condition exists on the opposite side.


was observed that on the 7th floor, the sheet rock

for the elevator shaft across from the Progressive

Care Unit doors is not sealed to the deck.


was observed that on the 7th floor, in the staff

only elevator lobby, a pipe penetration is not

sealed.



unfinished shell, there is a shaft at the stairwell

above the ductwork that is not sealed. There is

one sheet of fire rated gypsum covering the

opening. It is not sealed around the drywall.


was observed that on the 6th floor unfinished

shell, the two-hour shaft on the backside of that

stairwell is not sealed. There is a penetration

inside that shaft. Also, above the ductwork there

is penetration.


was observed that on the 10th floor inside of

Stairwell 12 through the access opening, there

are unprotected penetrations to the shaft at the

patient ' s room.


was observed that on the 7th floor inside stairwell

12 through the access opening, there are

unprotected penetrations to the shaft at the

patient ' s room.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

ID

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was observed that on the 7th floor inside Stairwell

12, there are two wooden 2 x 4's in the adjoining

shaft and a considerable amount of combustible

garbage.


was observed that on the 5th floor, there is a

large penetration to the elevator shaft on the

corridor side that is not sealed.


was observed that on the 5th floor in the Elevator

Equipment Penthouse, the shaft walls are not

sealed to the deck.


was observed that on the 3rd floor at the stairwell

outside of the CCL Point of Care Testing Room,

the shaft is not sealed at the deck.


was observed that on the 3rd floor, the pipe

chase in stairwell #12 has approximately 10




closed stairwell leading from third floor to the

fourth floor, there are unprotected penetrations at

the top and it is not sealed up the wall beside the

concrete pillar.


was observed that on the 3rd floor, the Electrical

Room's back wall is part of a two hour rated shaft

and is not properly sealed at the floor level.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

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(X4) ID

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was observed that on the 3rd floor, the Kitchen

Prep Area, the shaft that goes from the top to the

bottom of the hospital, has penetrations that are

not sealed.



approximately 6 penetrations in the pipe chase

located in stairwell #12.


was observed that on the 2nd floor, in the

ambulance equipment room, there is a shaft in

the closet that has unsealed penetrations.


was observed that on the 2nd floor, the electrical

room shaft is not sealed around the sprinkler

piping.


was observed that on the 1st floor at the 2-hour

wall in the corner of the radius where the

electrical room adjoins the radius, it is not sealed

at the deck.



Maintenance/Conference Room, the vertical shaft

has approximately 5 penetrations through the

wall.


was observed that on the 1st floor in the Storage

Room behind Elevator Mechanical Room, there

are multiple pieces of gypsum that have been

puzzled together and are not sealed.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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was observed that on the first floor and ground

level, the two story atrium is open to both stories.


was observed that on the 1st floor, inside stairwell

#12, the pipe chase has several penetrations.


was observed that on the ground and first floors,

the atrium is not properly separated with

construction that will provide a one hour rating.


was observed that on the ground floor, the

swinging door that leads into the elevator bank is

part of the one hour rating of the atrium not a

rated door which will close and latch

automatically.


was observed that on the all floors in all elevator

shafts, the liner is not properly sealed where it

meets the concrete beams/columns, there is

combustible foam used for penetrations, there is

wood in the shafts and there are vents in the top

that are unprotected.



outside of 6 bank elevator, there are unprotected

penetrations to the stairwell.


was observed that on the 4th floor in the storage

room across from unit director of OR Services

Office, there are unprotected penetrations and

the shaft is not sealed to the deck.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

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was observed that on the 4th floor in PACU

above Bay 4, there are unprotected penetrations

to the 2 hour shaft.



Anesthesia Ready Room, the 2-hour shaft wall is

not sealed.



shaft that is beside CTL Office, there are

unprotected penetrations and liner is not sealed

at the joints.


was observed that on the 4th floor in the shaft at

the OR Break Room, the access panel door is not

rated.


was observed that on the 4th floor in the shaft at

the OR Break Room, the shaft wall is not sealed

at the deck.











activation of:

K 021


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

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19.2.2.2.6, 7.2.1.8.2





Findings include:


was observed that on the 3rd floor in the food

service area there is a fire door held open by an

electro-magnetic hold open device. However, no

smoke detector has been installed for proper

operation.


was observed that on the 2nd floor at the MRI/CT

Waiting Room, there is no smoke detection at the

2-hour barrier for the doors.


was observed that on the 4th floor at the two-hour

barrier doors outside of OR Manager ' s Office,

there is no smoke detection at the 2-hour fire

barrier for the doors.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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occupants. 7.10.1.4


K 022



Findings include:



new elevators, an exit sign is above the lay-in

ceiling.


was observed that on the 2nd floor, at the South

to West breakthrough, the exit sign is partially

obstructed by a bulkhead.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

ID

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was observed that on the 3rd floor outside

stairwell #6, there is no exit sign directing

occupants to the discharge.



4, the exit signage leads to an incorrect route.



outside of surgical rooms 18, 19, and 20, there is

no exit sign to indicate travel path at the end of

the corridor.


was observed that on the 4th floor in the six-bank

elevator lobby, the exit sign is obstructed.
















19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4

K 025


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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Findings include:



cross corridor doors leading into the CCU, two

penetrations to the smoke barrier by conduit are

not sealed.



Women's Locker Room, there are 2 penetrations

of the smoke barrier along the back wall that are

not properly sealed.



barrier at the Pharmacy, there are unprotected

penetrations.


was observed that on the 5th floor at the

Mechanical Room and elevator, there are

unprotected penetrations to the smoke barrier.



barrier outside double doors to Mechanical Room,

there are unprotected penetrations.



East corridor in the smoke barrier, there are 7

large pipes sealed with combustible expanding

foam, and covered with black sealant.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

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TAG

(X4) ID

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East corridor, there are unprotected penetrations

above the smoke barrier doors by 4 pipes.



barrier in the Mechanical Room to the left, there

are two vent pipes that are sealed with

combustible foam.



Mechanical Room, there are unprotected

penetrations in the smoke barrier at the back,

right corner.



Conference Dining Area, there are approximately

3 large holes cut into the sheet rock of the smoke

barrier that are not sealed.


was observed that on the 3rd floor, at the

entrance to the Café, a sprinkler pipe is not

properly sealed and conduit is not sealed in the

smoke barrier.


was observed that on the 3rd floor, inside the

Catering Lead Manager's Office, the back wall of

the office is part of the smoke barrier. There is a

duct that is not properly sealed in this wall.



entrance into the Emergency Department outside


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

(X5)

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DATE

ID

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of the Conference Room, the smoke barrier is not

sealed to the deck; there is an area where the

drywall has been added and is not sealed.



Emergency Department Lobby, above the soft

drink machines, there are approximately 4

penetrations to the smoke barrier that are not

sealed.


was observed that on the 2nd floor, Emergency

Department, in the hallway containing restrooms,

above the access panel door, approximately 5

unprotected penetrations by piping are in the

smoke barrier, and the barrier is not properly

sealed to the deck.



room that is labeled "Employees Only" there is a

penetration to the smoke barrier.


was observed that on the 2nd floor at Registration

#4 and Environmental Services, the smoke

barrier above the doors is not complete to the

deck and there are unprotected penetrations.


was observed that on the 2nd floor, in the Locker

Room, the doors located between the actual

Locker Room and the Employee Lounge in the

smoke barrier does not have a closer.


was observed that on the 2nd floor, Employee

Locker Room, the barrier is not sealed properly to


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

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DATE

ID

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the deck. There are wires going through the

barrier wall that are not sealed.


was observed that on the 2nd floor at the Break

Room in the smoke barrier, there are unprotected

penetrations.


was observed that on the 2nd floor in the smoke

barrier at ER Bays 40, 41 and 42, there are large

pieces of gypsum missing.


was observed that on the 2nd floor, where the

smoke barrier goes behind the Lab, there are

penetrations by wires that are not sealed.



MRI, at the double doors, a duct penetrates the

smoke barrier and is not properly sealed. The

walls are not properly sealed at the deck.


was observed that on the 1st floor in the back of

the Mechanical Room that shares a wall with

Medical Records Storage Room, the smoke

barrier is not sealed and there are unprotected

penetrations.


was observed that on the 1st floor in the Medical

Records Storage Room, the entire area is a

smoke barrier and has unprotected penetrations

and not sealed to the deck.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

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barrier at the double doors beside the RN Work

Room, there are unprotected penetrations.


was observed that on the 4th floor at the smoke

barrier inside the Men's locker room above locker

#4, there are unprotected penetrations.



barrier at the smoke doors at the four-bank

elevators, there are unprotected penetrations.



barrier at the 6 bank elevators, there are multiple

unprotected penetrations above the door.



barrier at the Computer Room outside double

doors to the Operating Room, there are




East corridor, there are unprotected penetrations

to the smoke barrier and the wall is not sealed to

the deck.



between South and East, there are unprotected

penetrations to the smoke barrier .



barrier at the double doors outside the elevator

lobby, the doors are not rated, there are


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

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unprotected penetrations above the door and is




barrier at the double doors leading to PACU, the

wall does not extend above the doors.



barrier to the left of the double doors to PACU,




barrier above the double doors into the OR, there

are unprotected penetrations and the wall is not

complete.



barrier above the specimen room door in the OR,




barrier at PACU Unit Director Room, there are




barrier across from PACU, there are unprotected

penetrations.


was observed that on the 4th floor in the closet

beside the Specimen Room, the smoke barrier is

incomplete above the ceiling to the left.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG







PAPA/PACU Unit Director Office, the smoke

barrier is incomplete above the ceiling.


was observed that on the 4th floor in the alcove at

the double doors to PACU, the smoke barrier is

not sealed.


was observed that on the 4th floor in the alcove

outside of Pediatric Post-op, there are

unprotected penetrations in the smoke barrier.



barrier wall at the second set of double doors to

the PACU, the wall is not sealed at the deck and




barrier wall at the PACU Beds 8, 11, and 12,


not sealed at deck.



barrier at the back of the OR leading to the

PACU, and outside of OR, there are unprotected

penetrations.



violation occurs and the adjoining smoke partition.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

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TAG















19.3.7.7


K 027



maintained.

Findings include:


was observed that on the 2nd floor, the smoke

barrier doors between the Soiled Utility Room and

the Lab in the ER, one leaf of the doors is

dragging on the floor and is not closing.



barrier at the Senior Director of OR office, the

door does not have a closer and is not fire rated.


was observed that on the 4th floor in the Unit

Director of OR Services Office, the smoke barrier

door is not rated.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





was observed that on the 4th floor at the

Specimen Room, the door is not rated and is

missing the closer.



beside the specimen room, the door is missing a

closer.
















permitted. 19.3.2.1


K 029



Findings include:


was observed that on the 7th floor, the Utility


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

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Room across from the conference room has

penetrations to the left side wall and the walls are



was observed that on the 7th floor Pantry has 5

penetrations that are not sealed and the corner of

the room is not smoke tight.


was observed that on the 7th floor, in the Soiled

Utility Room, penetrations of walls have not been

sealed.


was observed that on the 6th Floor in the Clean

Linen Room outside of Pharmacy, the door is

being propped open by a clothes rack.


was observed that on the 6th floor, the Equipment

Storage Room is not being maintained smoke

tight and the door does not have a closer.



Clean Utility Room in the radius, there are



was observed that on the 6th floor Clean Utility

Room in the radius, there are unprotected

penetrations.


was observed that on the 6th floor, the Soiled

Utility Room in the radius has a large unsealed

penetration above the ceiling at the door. The

opening has been made for the translogic


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





system. Also, penetrations resulting from

domestic water lines have been filled with

combustible foam.


was observed that on the 5th floor, the Employee

Health Storage Room is not smoke tight.


was observed that on the 5th floor Mechanical

Room, unprotected penetrations exist in the walls.



Environmental Services Equipment Room, the

door has a gap towards the bottom in excess of

1/8th an inch.



Housekeeping Storage Room, there are

approximately 2 penetrations that need to be

sealed.


was observed that on the 3rd floor in the OR

Materials Management Storage Room, the door

is being propped open.


was observed that on the 3rd floor in the Storage

Room of the Materials Manager Surgical Services

Office, there are no door closers.



Materials Manager of Surgical Services Office,


not sealed at the deck.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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was observed that on the 3rd floor, near the

checkout register, the Storage Closet is not

smoke tight and the door does not have a closer.



Materials Management Storage Room for OR,




Housekeeping Closet door is propped open so

that the door will not close and latch.



Management Storage Room, there are

unprotected penetrations to the walls.


was observed that on the 3rd floor, the double

doors to Bulk Coffee Supply Area are not rated

and there are approximately 4 penetrations to the

wall.


was observed that on the 3rd floor, the wall to

Central Storage is not sealed to the deck.


was observed that on the 3rd floor, the doors to

Central Sterile do not have the proper rating and

the doors do not latch as required.


was observed that on the 3rd floor at Central

Sterile, there are unprotected penetrations to the


A. BUILDING





(X3) DATE SURVEY

COMPLETED



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entire wall.


was observed that on the 3rd floor at Central

Sterile, the second entrance door is not sealed to

the wall and there are unprotected penetrations.



entrance to the OR Materials Management, doors

are obstructed by boxes. The door is also

propped open.


was observed that on the 3rd floor, there are

penetrations in the one hour rated wall for the Dry

Food Storage.


was observed that on the 3rd floor, the fire door

for the storage closet in the meal prep area was

propped open.


was observed that on the 3rd floor food services

area, above the door that leads to the back of

Skyline Grill there are 4 penetrations in the rated

wall. (NOTE: See definition of hazardous areas

3.3.13.2; this area has many heat producing

appliances; and 8.4.1.1)


was observed that on the 2nd floor, the Storage

Room door does not have a closer.



unsealed penetrations between the Storage

Room and the Environmental Storage Room.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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was observed that on the 2nd floor, Pain Center,

Room 8, has been turned into a storage room

and is not smoke tight.


was observed that on the 2nd floor outside of

Pediatrics, the shell area contains storage and

trash and is not separated.


was observed that on the 2nd floor, the door to

the HazMat room does not close and latch

automatically.



Emergency Department Soiled Utility Room, there

are unprotected penetrations.


was observed that on the 2nd floor in the Soiled

Utility Room at the EMS entrance, the walls are




leading from the outside into Engineering, the

smoke partition is not sealed to the deck.


was observed that on the 1st floor, 2 conduits are

not sealed above the doors entering the

Maintenance Area. There are 8 penetrations

inside the Maintenance Area to the left of the

door.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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was observed that on the 1st floor, a waste line

and wires are not sealed in the Storage/Lighting

Room.


was observed that on the 1st floor,

Maintenance/Computer Room door has been

removed. Also, there are penetrations to the

back wall that are not sealed.


was observed that on the 1st floor

Maintenance/Computer area, pipe penetration is

not sealed.


was observed that on the 1st floor, the doors to

the Maintenance Shop will not close. There is no

coordinator on these doors.


was observed that on the 1st floor, sprinkler

piping and a duct above the exit sign at the

Storage Room in the corridor are not sealed.


was observed that on the 1st floor Mechanical

Room, there are approximately 15 penetrations

in this area that are not sealed. Combustible foam

sealant has been used extensively in this area.


was observed that on the 1st floor, Medical

Records, it does not appear that the entire room

is separated. There are penetrations to the walls,

and the back wall does not appear to have a

rating.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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was observed that on the 1st floor, required doors

have been removed in the HIM Department.


was observed that on the 1st floor inside Quality

Management Office, there are unprotected

penetrations to the smoke partition wall adjoining

hazardous area.


was observed that on the ground floor, there are

several penetrations in the Storage Room behind

the elevator bank that are not sealed.


was observed that on the 1st floor, inside the

small Electrical Room, the back side of the

Storage Room has combustible foam used for

one of the penetrations and the vent pipe.



additional Storage Room behind the elevator

bank has a hole in the wall and is not smoke tight.


was observed that on the 6th floor in Cath Lab

Sterile Supply, the door is being propped open

with a cart.


was observed that on the 6th floor in Profusion

Storage, the door closer is missing.


was observed that on the 4th floor in the Central

Storage Room of the OR, the smoke partitions

are not sealed to resist the passage of smoke

and all doors are missing closers.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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was observed that on the 4th floor in Storage

Room E2, there are unprotected penetrations and

walls are not sealed to the deck.



Storage Room 1, the wall is not sealed to the

deck, there are unprotected penetrations and the

door is missing a closer.



Storage Room 2, the door will not close.


was observed that on the 4th floor in the shell for

future OR 25, it is now being used for storage and

is not properly protected.


was observed that on the 4th floor in the shell for

future OR 21, it is now being used for storage and

is not properly protected.


was observed that on the 4th floor in Work Core

Storage Room 2, the walls are not sealed to the

deck, there are unprotected penetrations and the

doors are missing closers.



Equipment Storage Room N2, there are



was observed that on the 4th floor outside Work


A. BUILDING





(X3) DATE SURVEY

COMPLETED



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Core Storage Room, there are unprotected

penetrations.


was observed that on the 4th floor in soiled utility

room on the back side of the six-bank elevators,

the door is not latching.


was observed that on the 4th floor at door above

decontamination pass through Storage Room, the

smoke partition is not complete.


was observed that on the 4th floor in PACU, the

Soiled Utility Room door will not latch.


was observed that on the 4th floor at PACU, the

Clean Linen Room door will not latch.



Anesthesia Work/Storage Room, the smoke

partition is not sealed to the deck and there is no

door closer, and there are penetrations that are

not sealed.



are located.




Laboratories employing quantities of flammable,

combustible, or hazardous materials that are

considered a severe hazard are protected in

K 031


A. BUILDING





(X3) DATE SURVEY

COMPLETED



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accordance with NFPA 99. (Laboratories that are

not considered to be a severe hazard meet the

provisions of K29.) Laboratories in health care

occupancies and medical and dental offices are

in accordance with NFPA 99, Standard for Health

Care Facilities. 10.5.1



maintain the protection an area of the Laboratory

considered a severe hazard.

Findings Include:


patients in the area where they are located.




Exit components (such as stairways) are

enclosed with construction having a fire

resistance rating of at least one hour, are

arranged to provide a continuous path of escape,

and provide protection against fire or smoke from

other parts of the building. 8.2.5.2, 19.3.1.1

K 033


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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maintain the fire resistive rating of an exit

component.

Findings Include:


was observed that on the 3rd floor in the exit

discharge corridor, the 2-hours double doors at

the end of hallway were removed.



discharge corridor at the Nitrogen and Nitrous

oxide Storage Room, the doors are not rated.



Material Management, there are unprotected

penetrations to the 2-hour exit access corridor

above the doors.


was observed that on the 3rd floor above the OR

Materials Management there is a large patch in

the drywall that has not been sealed in the exit

discharge corridor.



discharge corridor at Material Manager's Office,

the walls do not appear to be 2-hour rated

construction.


was observed that on the 3rd floor exit discharge

corridor, the walls are not sealed to the deck


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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along the left side.


was observed that on the 3rd floor above

entrance to exit corridor, there are unprotected

penetrations and not sealed to the deck.






Travel distance (exit access) to exits are in

accordance with 7.6. 19.2.5.10


K 036


ensure that the travel distances are in accordance

with the Life Safety Code.

Findings Include:








7.1. 19.2.1

K 038


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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accessible.

Findings Include:


was observed that on the 1st floor at double

doors to Engineering Hallway, the magnetic locks

were not de-energized during a fire alarm.






Exit and directional signs are displayed in

accordance with section 7.10 with continuous

illumination also served by the emergency lighting

system. 19.2.10.1


K 047


display exit signs with continuos illumination.

Findings Include:



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

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DATE

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was observed that on the 2nd floor in the MRI

Control Room, there is an exit light not

illuminated.


was observed that on the 1st floor there is an exit

that goes up the stairs to the third floor and exits

into a horizontal exit. There is no exit sign over

the door on the first floor leading into the stairwell.


was observed that on the 1st floor, the directional

exit sign outside the mechanical room does not

direct occupants into the stairwell.


was observed that on the 1st floor in the Prep

Kitchen, the exit sign leads into the Board Room

instead of to an exit.










K 048




Findings Include:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

(X5)

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DATE

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was observed that on the all patient care floors,

the written emergency procedures manual was

not available at the nurses' stations. It was

indicated that the procedures were on line, they

are not in printed form and are not immediately

available for use by the nursing staff.



Pediatric Emergency Department, based on

interviews with 4 nursing staff, there are no

emergency evacuation procedures manual

located at the nurses ' station.



ambulance entrance in the Emergency

Department, based on interviews with 2 nursing

staff, there are no emergency evacuation

procedures manual located at the nurses '

station.














K 050


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

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alarms. 19.7.1.2





Findings include:



Pediatric Emergency Department, based on

interviews with 4 nursing staff, they have not had

a fire drill for over a year.



Ambulance entrance in the Emergency

Department, based on interviews with nursing

staff, they have not had a fire drill for over a year

and also they stated that they have not received

training on the emergency evacuation manual.


was found during the review of records provided

by Carilion, the facility failed to conduct fire drills

in accordance with guidelines in NFPA 101.

Findings include: Fire drills are not being

conducted by sounding the fire alarm system,

only by announcements.






A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

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9.6


K 051



system.

Findings include:


was observed that on the 6th floor, shell space

pull station is not in service.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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East corridor, there is no fire alarm pull station at

the East building.



Room, documentation shall be provided to show

that the required decibel level above ambient

noise is provided for the fire alarm system.













K 052




Findings include:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

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The fire alarm system is being tested; however,

the report does not conform to requirements set

forth in 1999 NFPA 72, 7-5.2.2











K 054




Findings include:


was determined during review of records that the

smoke detectors are not being tested for

sensitivity rating as required. Also, the report is

not in an acceptable format as required by NFPA

72, Sections 7-3.2.1 & 7-5.2, 1999 Edition.


was observed that on the 1st floor inside the Bed

Repair Shop and Mechanical Repair Shop, the

smoke detectors appeared to be disabled.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

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Communications Room of Engineering above the

fire panel, the smoke detector is not installed in

accordance with NFPA 72.



Room E2, the detector is not secured to the

ceiling.




















K 056



Findings include:


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

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(X4) ID

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was observed that on the all floors, there is no

sprinkler protection in patient rooms and offices

that have a soffitt at the windows.



Room, a sprinkler is located outside of a Storage

Room and is 3-3/4" off the wall, and 23" from the

ceiling.



Room, there are areas without sprinkler

coverage.


was observed that on the 5th floor inside

Mechanical Room in the Small Storage Room to

the left, there are high-temperature heads and no

high-temperature devices.


was observed that on the 5th floor throughout the

Mechanical Room, there are 4-foot wide

obstructions without sprinkler coverage.


was observed that on the 2nd floor, there is no

sprinkler protection in the rear office at stairwell.

(The sprinkler is actually above the lay-in ceiling)


was observed that on the 2nd floor, there is no

sprinkler coverage in the Electrical Closet inside

the office at the rear of the building.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

(X5)

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ID

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was observed that on the 2nd floor, Storage

Room, there is no sprinkler protection in this

room.


was observed that on the 2nd floor in the area

being used as the Psych area, Room 9 does not

have proper sprinkler coverage (the area behind

the column).


was observed that on the 2nd floor in Bays 28-31

at the back shelf bulk area, there is a insufficient

sprinkler coverage.


was observed that on the 2nd floor at alcove

across from hall 8, there is insufficient sprinkler

coverage.


was observed that on the 2nd floor inside the

Data Room outside double elevators at the

Emergency Department, there is a insufficient

sprinkler coverage.


was observed that on the 2nd floor in ER to OR

elevator, there is a valve that controls a pipe into

the elevator shaft that is not marked, as required

by 1999 NFPA 13, 3-8.3..


was observed that on the 1st floor in the Painters'

Storage Room, there is a insufficient sprinkler

coverage under the duct.


was observed that on the 1st floor in the Fire


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

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Pump Room, the jockey pump and the fire pump

controller sensing lines are tied in at the same

location.


was observed that on the 1st floor large

Mechanical Room, there are ducts larger than 4

feet across with no sprinkler protection.


was observed that on the on all floors, the

sprinkler valves are not marked with what areas

they control.



Residents' Lounge beside the Coding Offices,

there is insufficient sprinkler coverage in the

alcove with a computer.


was observed that on the 1st floor elevator lobby,

inside the Fire Alarm Panel Room, proper

sprinkler protection is not provided.


was observed that on the 1st floor in the large

Boardroom, there is no sprinkler coverage in the

arch.


was observed that on the 1st floor in the Medical

Director of Pediatric Services Office there is an

area that is not protected by sprinklers.



Administrative Secretary's Office, there is no

sprinkler coverage in the newly added closet.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

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DATE

ID

PREFIX

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was observed that on the ground floor at the

entrance to the ER Parking, the first sprinkler

branch line has sprinklers that are 63 inches

apart.


was observed that on the ground floor to the left

side of the Coffee Shop, there are 2 sprinklers 65

inches apart.


was observed that on the ground floor parking

garage mechanical room, the dry sprinkler riser

does not have controls identified as required.


was observed that on the 6th floor outside of

director of Invasive Cardiology and Manager of

Cath Lab, there is insufficient sprinkler coverage.


was observed that on the 4th floor at the two-hour

barrier doors outside of OR Manager ' s Office,

there is insufficient sprinkler coverage.





Required automatic sprinkler systems have

valves supervised so that at least a local alarm

will sound when the valves are closed. NFPA

72, 9.7.2.1

K 061


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

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DATE

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PREFIX

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TAG







supervise automatic sprinkler control valves as

required.

Findings Include:

This has the potential to affect the area controlled

by the valve.








25, 9.7.5


K 062



Findings include:


was observed that on the 7th floor Electrical

Room a sprinkler is painted.


was observed that on the 6th floor Women's


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

(X5)

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DATE

ID

PREFIX

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(X4) ID

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Locker Room, a sprinkler escutcheon is missing.


was observed that on the 5th floor Employee

Health Storage Room, storage is not maintained

18" below the sprinkler deflector.


was observed that on the 5th floor outside

entrance to Mechanical Room, there is an

escutcheon plate missing.


was observed that on the 5th floor corridor

between South and East, there are wires

attached to and resting on the sprinkler piping the

entire length of corridor.



Room, storage is not being maintained 18" below

sprinkler deflectors.



Room, the sprinkler coverage is obstructed by

two boxes at the expansion joint.



Room, wires and cables are resting on sprinkler

piping.


was observed that on the 3rd floor outside the

CRT Storage Room, there are wires attached to

the sprinkler piping.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





was observed that on the 3rd floor, outside the

restricted access elevator lobby, a sprinkler



was observed that on the 3rd floor, elevator lobby,

sprinkler escutcheon is missing.



elevators, the ceiling grid is supported by

sprinkler piping.


was observed that on the 3rd floor outside the OR

Materials Management Storage Room, there is a

pipe resting on the sprinkler pipe.


was observed that on the 3rd floor, an

escutcheon is missing from the sprinkler at the

Consultation Room.



Materials Management Office, there is an

escutcheon plate missing.



entrance to exit corridor, there an escutcheon

missing.


was observed that on the 3rd floor at the back

side of the two hour shaft next to the fire

extinguisher, an escutcheon is missing from the

sprinkler.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

(X5)

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DATE

ID

PREFIX

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(X4) ID

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was observed that on the 2nd floor, electrical

closet at the Chest Pain Center, the sidewall

sprinkler is installed improperly.


was observed that on the 2nd floor, the sprinkler

is obstructed by the TV in the Employee Locker

Room.


was observed that on the 2nd floor, Chest Pain

Center, at Room 1, the sprinkler is obstructed by

the Nurse call light.



Exam room #35, sprinkler escutcheon is missing.


was observed that on the 2nd floor, ER, outside

of Bay 28, sprinkler escutcheon is missing.


was observed that on the 2nd floor, there is a

sprinkler without an escutcheon at the Med Com

Room.


was observed that on the 2nd floor ER area, the

Ambulance Equipment Room in Peds, storage is

not being maintained 18" below the deflector.


was observed that on the 2nd floor inside data

room at double elevators in the Emergency

Department, there is a painted sprinkler.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG





was observed that on the 2nd floor, in the ER

above the ceiling at the elevator lobby, the

sprinkler piping has wires attached.



corner from the MRI Waiting Room in an office,

there ' s an escutcheon plate missing.


was observed that on the 1st floor in the Electrical

Room, the guard under the duct is missing.


was observed that on the 1st floor in the Electrical

Room towards the outside wall, the sprinkler

under duct F73 is missing the guard.


was observed that on the 1st floor in the Fire

Pump Room, the fire pump isolation transfer

switch power indicator lamps are not lit, showing

that it has no power.



at Mechanical Room, there is a bundle of wires

that are laying on the sprinkler piping.



escutcheon is missing from the sprinkler inside CI

Coding.


was observed that on the 1st floor in the entire

corridor leading to Conference Rooms E and F,

wires are attached to the sprinkler piping with zip

ties.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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DEFICIENCY)

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(X4) ID

PREFIX

TAG







outside of Conference Room E, an escutcheon

plate is missing.


was observed that on the 1st floor outside of the

Board Room an escutcheon is missing from the

sprinkler.



Parking Garage, the sprinklers are corroded.


was observed that on the ground floor, in the

Storage Room off the elevator bank, escutcheon

is missing from sprinkler.


was observed that on the 1st floor in the ER

Parking, the low-clearance sprinkler heads are

missing guards.



Escalator Room, an extension cord is being used

to hang a fan which is coiled and supported by

the sprinkler pipe.



atrium, there is paint on all of the sprinkler covers.



bottom of elevator shaft 1 and 2, the sprinkler

heads are obstructed.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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bottom of elevator shaft 3 and 4, the sprinkler is

obstructed.



bottom of elevator shaft 3 and 4, the sprinkler

guard is missing and the sprinkler is loaded with

debris.



Block Rooms, there is an sprinkler escutcheon

missing.



Storage Room N2, there is storage too close to

the sprinkler deflector.



Environmental Services Storage Room beside

room N2, is missing an escutcheon.



Work Core Room, there are wires attached to the

sprinkler piping.


was observed that on the 4th floor in the Gas

Storage Room, a ceiling tile is missing.


was observed that on the 4th floor in the Soiled

Utility Room on the back side of the six-bank


A. BUILDING





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elevators, an escutcheon and ceiling tile are

missing.


was observed that on the 4th floor in the Office

outside of 6 bank elevator, the sprinkler pattern is

obstructed by storage.


was observed that on the 4th floor at the corner of

the South to East corridor, there is a painted

sprinkler in the bulkhead and there is an

institutional-style head not installed in accordance

with its listing.


was observed that on the 4th floor in the Electrical

Room across from OR Director / OR Manager ' s

Office, the sprinkler is painted.



beside the Specimen Room, an escutcheon is

missing.


was observed that on the 4th floor in the Medical

Director of Anesthesia Library, there is insufficient

sprinkler coverage.








K 064


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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9.7.4.1. 19.3.5.6, NFPA 10




Findings Include:


was observed that on the 3rd floor in the Medical

Gas Storage Rooms, the dry extinguishers are

not tagged with a current inspection date.



CS1, there is a carbon dioxide extinguisher in

place of an ABC extinguisher. It is also

obstructed.






Smoking regulations are adopted and include no

less than the following provisions:

(1) Smoking is prohibited in any room, ward, or

compartment where flammable liquids,

combustible gases, or oxygen is used or stored

and in any other hazardous location, and such

area is posted with signs that read NO SMOKING

or with the international symbol for no smoking.

K 066


A. BUILDING





(X3) DATE SURVEY

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(2) Smoking by patients classified as not

responsible is prohibited, except when under

direct supervision.

(3) Ashtrays of noncombustible material and safe

design are provided in all areas where smoking is

permitted.

(4) Metal containers with self-closing cover

devices into which ashtrays can be emptied are

readily available to all areas where smoking is

permitted. 19.7.4


Based on observations, the facility to follow the

smoking regulations as required by the Life

Safety Code.

Findings Include:


was observed that in the 6th floor unfinished

shell, in one corner there is smoking material.


was observed that on the 5th floor restrooms

outside of Employee Health, the restrooms

appear to have been smoked in.



lower clearance of the ER lot, there is smoking

material all along the wall and in the corners.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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19.5.2.2


K 067

Based on observations, the facility to install


specifications.

Findings Include:


was observed that on the 6th floor radius Nurses'

Station, there is combustible spray foam around

two water pipes at or around that bulkhead.



East corridor, there are combustibles in the

plenum ceiling with cups, plastic, etc.



East corridor at the 2-hour barrier, there is

exposed facing on the insulation that is

combustible.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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elevator, there is plastic wrapping in the plenum.



Room, the duct shaft walk-through has an outlet

inside of it and there is no fire/smoke damper

from the duct that goes through the rated wall.


was observed that on the 5th floor Stairwell 11,

there are duct penetrations with no damper

protection.



Room, a mechanical damper in this area is not

wired.



Management, the dampers are installed

incorrectly.



entrance to exit corridor, there are no dampers

installed in the duct work.



entrance to exit corridor, there is no access to the

fire dampers.


was observed that on the 3rd floor, Stairwell #6,

there is wood bracing above the ceiling

supporting the sprinkler lines.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






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Emergency Department Soiled Utility Room, the

duct work is not properly protected.


was observed that on the 2nd floor in the soiled

utility room at the EMS entrance, the there is no

damper in the duct work.


was observed that on the on all floors in all areas,

the fire dampers do not have a currently dated

fusible link. They are all stamped 1993.


was observed that on the 1st floor in the Elevator

Equipment Room, there are no fire dampers in

either of the ducts that penetrate the two-hour

wall.



Residents' Lounge, the location of the damper is

not marked.



Conference Room D, there is an electrical box

mounted in the plenum with 2 transformers

plugged into it with wires connected by electrical

tape.



location of all dampers is not marked as required.

This statement applies to all floors.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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was observed that in the underground parking

garage area in an access panel, there are fire

dampers that have activated. One damper is

completely closed, one is partially closed.


was observed that on the ground floor between

the Garage and the Coffee Shop, the location of

the dampers are not marked and they were

activated.



Room E2, the duct work is not protected.



Equipment Storage Room 1, there is no damper

above the door.



Equipment Supply Storage Room N1, there is no

damper installed in the duct.



East corridor at decontamination pass through,

there is a large bundle of plastic in the plenum.


was observed that on the 4th floor in the plenum

space beside the elevator, the entire length of the

Mountain Addition there is plastic draped the

entire height and length of the wall.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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East corridor, there is a garden hose being used

as an HVAC drain line in the plenum.



East corridor, there is a large electrical switchgear

installed in the plenum.


was observed that on the 4th floor in the alcove at

Pediatric Post-Op, there is wood in the plenum

and electrical switch gear installed in the plenum.



PACU, the mirror is being held by wood in the

plenum.


was observed that on the 4th floor in PACU at

Bay 4 and Bay 3, there is wood and bed linen in

the ceiling.


was observed that on the 4th floor inside the

PACU at Bed 8, there are electrical high-voltage

boxes installed in the plenum.


was observed that on the 4th floor in PACU, the

entire area has wood in the plenum space.



shaft that is beside CTL Office, there are

combustibles being stored in the plenum.




A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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Cooking facilities are protected in accordance

with 9.2.3. 19.3.2.6, NFPA 96


K 069


maintain cooking facilities in accordance with the

Life Safety Code requirements.

Findings Include:


was observed that on the 3rd floor the nozzles for

the hood system in the Skyline Grill have a

build-up of grease.






Portable space heating devices are prohibited in

all health care occupancies, except in

non-sleeping staff and employee areas where the

heating elements of such devices do not exceed

212 degrees F. (100 degrees C) 19.7.8


K 070



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(X3) DATE SURVEY

COMPLETED



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prohibit portable space heaters in accordance

with the Life Safety Code requirements.

Findings Include:



Management Office, the cubicle to the left has a

portable space heater that has an element that

can reach in excess of 212 degrees.


was observed that on the 1st floor in Quality

Management Office, the back left cubicle has a

portable space heater with an element that can

reach in excess of 212 degrees.


was observed that on the ground floor in the lobby

at the Information Desk, there are 3 portable

space heaters with elements that can reach in

excess of 212 degrees.











7.1.10

K 072


A. BUILDING





(X3) DATE SURVEY

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obstructions.

Findings Include:



two-hour barrier in the hallway, there are 9 beds

stored in the corridor.


was observed that on the 3rd floor at Stairwell #2,

six laundry carts, pallets, cardboard boxes, and

tables are being stored in the corridor.


was observed that in the corridor is being used for

storage, outside the Blood Bank on the 3rd floor.



elevators, there are pallets stored in the corridor.


was observed that on the 3rd floor outside OR

Material Management, the corridor is being used

to store 2 large carts of combustibles.


was observed that on the 3rd floor, the exit door

on the dock was obstructed by carts.


was observed that on the 2nd floor, Emergency

Department at Bay 31, there is a curtain pulled

across the main egress path.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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Pediatric Emergency Department, corridor is

used for storage of 3 clean utility carts, 3 beds, 3

cribs and 4 wheelchairs.


was observed that on the 1st floor, combustibles

are being stored in Stairwell #11.


was observed that on the 2nd floor, ER area,

while recognizing that some items need to be in

the corridor, such as crash carts, the corridors are



was observed that on the 2nd floor, one exit

leading out of the large Storage Room near

Pediatrics is obstructed by storage.



ambulance entrance in the Emergency

Department, there are 7 IV carts stored in the

corridor.


was observed that on the 1st floor in the Coding

Area, the egress width was reduced by a table.


was observed that on the 4th floor in the entire

back hallway, there are combustibles and

equipment being stored.


was observed that on the 4th floor outside OR 4,


A. BUILDING





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COMPLETED



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there is storage in the corridor with signs on the

wall indicating storage is routine practice.


was observed that on the 4th floor in the elevator

lobby at the Mountain Building, combustibles are

being stored in the lobby.


was observed that on the 4th floor beside

pharmacy, there are combustible linen carts full of

linens being stored in the corridor.









K 073




Findings Include:



are located.



A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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Draperies, curtains, including cubicle curtains,

and other loosely hanging fabrics and films

serving as furnishings or decorations in health

care occupancies are in accordance with

provisions of 10.3.1 and NFPA 13, Standards for

the Installation of Sprinkler Systems. Shower

curtains are in accordance with NFPA 701.

Newly introduced upholstered furniture within

health care occupancies meets the criteria

specified when tested in accordance with the

methods cited in 10.3.2 (2) and 10.3.3. 19.7.5.1,

NFPA 13

Newly introduced mattresses meet the criteria

specified when tested in accordance with the

method cited in 10.3.2 (3) , 10.3.4. 19.7.5.3


K 074


ensure that draperies and curtains used in the

facility meet the requirements of the Life Safety

Code.

Findings include:


was observed that on the 2nd floor, ER area Bay

31, documentation is needed to show that the

white curtains that cover the windows between

bays in this area are flame retardant.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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patients in affected area.




Soiled linen or trash collection receptacles do not

exceed 32 gal (121 L) in capacity. The average

density of container capacity in a room or space

does not exceed .5 gal/sq ft (20.4 L/sq m). A

capacity of 32 gal (121 L) is not exceeded within

any 64 sq ft (5.9-sq m) area. Mobile soiled linen

or trash collection receptacles with capacities

greater than 32 gal (121 L) are located in a room

protected as a hazardous area when not

attended. 19.7.5.5


K 075


ensure that soiled linen or trash receptacles do

not exceed a 32 gallon capacity.

Findings include:


was observed that on the 2nd floor, Triage Area,

a 45 gallon waste container is being stored in the

corridor.


was observed that on the 6th floor in the corridor,

there are 2-45 gallon trash bins unattended.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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outside of Surgical Rooms 18, 19, and 20, there

is a linen bin that is greater than 32 gallons that is

unattended.



Room 20, there is a 45 gallon trash bins

unattended.


was observed that on the 4th floor in the AOR

Break Room, the trash receptacle exceeds 32

gallons.






Medical gas storage and administration areas are

protected in accordance with NFPA 99,

Standards for Health Care Facilities.

(a) Oxygen storage locations of greater than

3,000 cu.ft. are enclosed by a one-hour

separation.

(b) Locations for supply systems of greater than

3,000 cu.ft. are vented to the outside. NFPA 99

4.3.1.1.2, 19.3.2.4

K 076


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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properly protect and administer medical gas

storage is protected in accordance with

requirements.

Findings include:


was observed that on the 3rd floor in the Nitrous

Oxide Room, the walls are not sealed to the deck

and the cylinders are not secured, as required by

1999 NFPA 99, 4-3.5.2.1.


was observed that on the 4th floor in the Gas

Storage Room, there are unprotected

penetrations and walls are not sealed at the deck,

as required by 1999 NFPA 99, 4-3.1.1.2.

.


was observed that on the 4th floor, the Gas

Storage Room door is not latching, as required by

1999 NFPA 99, 4-3.1.1.2..







99, Chapter 4.


K 077


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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installed properly.

Findings include:



4, the med gas emergency shut-off valves are

obstructed by carts and there is signage directing

storage to be placed there.



23, the med gas emergency shut off valves are

obstructed by environmental services carts.



Room 19, the med gas emergency shut-off valves

are obstructed by carts and there is signage

directing storage to be placed there.


was observed that identification of the med gas

piping system is improperly identified in

accordance with NFPA 99, 1999 Edition, Section

4-3.1.2.14.









K 103


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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Findings Include:



located.




Penetrations of smoke barriers by ducts are

protected in accordance with 8.3.6.


K 104


maintain the penetration of smoke barriers by

ducts are protected as required.

Findings Include:


was observed that on the 3rd floor, in the smoke

barrier outside of the equipment room, there are

no dampers installed in the duct work.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






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was observed that on the 4th floor, in the smoke

barrier wall at the computer room outside double

doors to the Operating room, there are no

dampers installed in the duct work.



barrier wall across from PACU, there are no

dampers installed in the duct work.



barrier at the PAPA/PACU Unit Director office,

there are no dampers installed in the duct work.

This has the potential to affect the affected

compartment and adjoining compartment.






K 130



Findings Include:


was observed that in the 6th floor unfinished

shell, there is an acetylene tank that is not

properly secured, and is not properly stored in an


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




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area rated for the acetylene. (NFPA 101, 8-4.3)



Mechanical Room, there are cylinders of

acetylene being stored without protection. NFPA

101, 8-4.3



closed stairwell leading from third floor to the

fourth floor, there are combustibles being stored

in this area. NFPA 101, 7-1.3.2.3








K 147



with NFPA 70.

Findings Include:


was observed that on the 7th floor in the Soiled

Utility Room, an electrical junction box needs an

approved cover.


was observed that on the 6th Floor, in the radius


A. BUILDING





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COMPLETED



B. WING _____________________________




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outside of Room 7, there is temporary lighting in

the ceiling.


was observed that on the 6th floor at the column

between Rooms 7 and 6 in the radius behind the

clock, there is open wiring.


was observed that on the 6th floor radius nurses'

station, there is a 4-inch by 4-inch junction box

that does not have an approved cover.


was observed that in the 6th floor radius, Soiled

Utility Room, there are two electrical junction

boxes in the ceiling that do not have approved

covers.



room, there is a light sitting on top of a duct that is

not mounted.



#2, temporary wiring has been left above the

lay-in ceiling.


was observed that on the 3rd floor, outside the

restricted access elevator lobby, temporary

lighting has been left in the ceiling.


was observed that on the 3rd floor, at the exit

from the Mountain View Café, there is a junction

box without an approved cover above the ceiling.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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(X4) ID

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Material Management, temporary lighting has

been left in the ceiling.


was observed that on the 3rd floor, in the kitchen

area, an office that has an extension cord being

used for permanent wiring.


was observed that on the 3rd floor, in the data

closet located at the back of the elevator lobby, a

junction box is missing an approved cover.


was observed that on the 2nd floor at the 2 hour

fire barrier, there is an electrical junction box

without an approved cover.



Emergency Department, above the access panel

door, there is a junction box without an approved

cover.


was observed that on the 2nd floor, in Exam

Room #35, the clock has been removed and

wiring is exposed.


was observed that on the 2nd floor in bay 29,

there is open wiring in the back.


was observed that on the 1st floor, there are

combustible tables being stored in the main

electrical room.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

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DATE

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was observed that on the 1st floor inside the bed

repair shop and mechanical repair shop, there

are multiple extension cords being used as

permanent wiring. There is a homemade unfused

multi-plug cord that is plugged into a power strip.

There is a power strip plugged into an extension

cord. There needs to be documentation verifying

the connection of the refrigerant tester is a listed

and approved system.


was observed that on the 1st floor in the very

back part of the electrical/mechanical room, there

is a junction box with open wiring.


was observed that on the 1st floor in the Card File

area, an extension cord is being used for

permanent wiring.


was observed that on the 1st floor in the coding

office at the fourth cubicle on the right, the cover

plate is missing from the bottom of the cubicle.


was observed that on the 1st floor in the back

cubicle on the left-hand side in coding, the cover

plate is missing from the electrical outlet in the

cubicle wall.



four-bank cubicle set of the Coding Office, there

is a cover plate missing from the first right

cubicle.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

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DATE

ID

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was observed that on the 1st floor, an

unapproved multi-plug outlet is located inside the

Infection Control Practitioner's office.



Management Office, the cubicle to the left has an

extension cord with a surge protector plugged to

it.



Conference Room D, there is an electrical box

with wires connected by electrical tape.


was observed that on the 1st floor in office of

Medical Director for Adult Services, the plug to

the surge protector is being pinched by the desk.


was observed that on the 1st floor in Conference

Room D, there power taps are plugged in series.


was observed that on the 1st floor in the Vice

Chair, Department of Emergency Medicine Office,

a power strip is plugged into another power strip

and not directly into an outlet.


was observed that on the ground floor to the left

of the Coffee Shop, there is an open junction box

at the light.



lobby, at the "monkey wall" under the walkway,


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there is temporary lighting in the plenum.


was observed that on the ground floor in the lobby

above the ceiling, there is an open junction box.


was observed that in the ground floor garage area

through an access panel, there are electrical

junction boxes without approved covers and

temporary wiring is still in place.



parking garage mechanical room, an electrical

junction box is not provided with an approved

cover.


was observed that on the 6th floor in the Medical

Director and the Cath Lab Office, there are power

taps plugged in series.


was observed that on the 6th floor in the Director

of Invasive Cardiology Office behind the clock,

there is open wiring.


was observed that on the 4th floor in the soiled

utility room on the back side of the six-bank

elevators, the cover is missing from a junction

box.



outside of 6 bank elevator, the electrical panel is

obstructed.


A. BUILDING





(X3) DATE SURVEY

COMPLETED



B. WING _____________________________




490024 01/21/2009

ROANOKE, VA 24033






DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

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TAG






was observed that on the 4th floor in corridor from

South to East at the East mechanical room, there

is temporary lighting still installed in the plenum.



between South and East, there is temporary

lighting still installed.


was observed that on the 4th floor in the OR

director / OR manager ' s office, there are surge

protectors plugged in series.



PACU in the corridor, there is an electrical box

without a cover in the plenum.






All existing elevators, having a travel distance of

25 ft. or more above or below the level that best

serves the needs of emergency personnel for fire

fighting purposes, conform with Firefighter's

Service Requirements of ASME/ANSI A17.3,

Safety Code for Existing Elevators and

Escalators. 19.5.3, 9.4.3.2


K 160



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ROANOKE, VA 24033






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have the elevator conform to the required

standards.

Findings Include:

This has the potential to affect any person on this

elevator, if the detector activated.




All existing escalators, dumbwaiters, and moving

walks conform to the requirements of

ASME/ANSI A17.3, Safety Code for Existing

Elevators and Escalators. 19.5.3, 9.4.2.2


K 161

Based on observations, the facility failed to that

escalators conform to standards.

Findings include:


was observed that documentation needs to be

provided to show that the escalators are

protected in accordance with the provisions of

Section 8.2.5.13 of the Life Safety Code.


patients using the escalators in the building.




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rooms)


from each other




an ignition source.


sprinklered. 19.3.2.7, CFR 403.744, 418.100,

460.72, 482.41, 483.70, 483.623, 485.623


K 211




Findings include:


was observed that on the Alcohol based hand rub

dispensers are not installed properly. Dispensers

were located above ignition sources in corridors

and patient rooms.






A. BUILDING





(X3) DATE SURVEY

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490024 01/21/2009

ROANOKE, VA 24033






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State fire marshal's report on Carilion Roanoke Memorial Hospital's fire safety violations

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Transcript of State fire marshal's report on Carilion Roanoke Memorial Hospital's fire safety violations