State Fire Marshal's Report On Carilion Roanoke Memorial Hospital's Fire Safety Violations

PRINTED: 07/21/2009
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING 03 - EAST BUILDING
B. WING _____________________________
490024 01/21/2009
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1906 BELLEVIEW AVENUE
CARILION MEDICAL CENTER
ROANOKE, VA 24033
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)
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 K 011
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:

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 Event ID: NC5621 Facility ID: VA0511 If continuation sheet Page 1 of 67
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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,
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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.

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

ensure that door openings in smoke barriers were
maintained.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

maintain the aisles or corridors serving as exit
access to at least 4 feet in width.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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

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..
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

Based on observations and review of records, the
facility failed to maintain, inspect, and test the
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.


PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
Portable fire extinguishers are provided in all

health care occupancies in accordance with
9.7.4.1. 19.3.5.6, NFPA 10

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..

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

ensure that piped in medical gas system was
installed properly.
Findings include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
K 130 NFPA 101 MISCELLANEOUS K 130
OTHER LSC DEFICIENCY NOT ON 2786

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

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
A. BUILDING 1A - SOUTH TOWER, UPPER 6 FLOORS
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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.)


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:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)



occupants. 7.10.1.4

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:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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..
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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..



Findings Include:

the facility failed to maintain written emergency
procedures at each nurses' station. This
All nurses' stations on all floors
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.



PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.


PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

specifications.
Findings Include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)


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

maintain the means of egress free of all
obstructions.
Findings Include:

locations:
15th Floor:
at approximately 1514 hrs. - Storage in elevator

lobby.

locations:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.




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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.




with NFPA 70.
Findings Include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)


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

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
This has the potential to affect the staff and

patients in the entire building.

PRINTED: 07/21/2009
A. BUILDING 04 - WEST BUILDING
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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.)


between buildings.
Findings include:

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

buildings.


of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4,
19.3.5.1

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.


PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.



PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.



PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)


activation of:


19.2.2.2.6, 7.2.1.8.2

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)



occupants. 7.10.1.4

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

Findings include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

Findings include:

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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.


PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

accessible.
Findings Include:

was observed that on the ground floor, W1
stairwell, the egress directional gate is loose,
obstructing egress.




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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.



PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.



PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)


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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.




PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.



PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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,
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

maintain the Laundry Chute as required.
Findings include:

linen chute room door is not self closing.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

linen chute does not appear to have sprinkler
protection in the chute itself.



7.1.10

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.




Findings Include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.




Findings Include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)


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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.



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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.


PRINTED: 07/21/2009
A. BUILDING 02 - MOUNTAIN
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
Mountain Building

Sprinkler Status: Fully Sprinklered


Fire.)


between buildings.
Findings include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

maintained.
Findings Include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

compartments.




Findings include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

Findings include:

noted that the equipment storage room door was
being held open by a wheelchair.



occupants. 7.10.1.4

Findings include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

Findings include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

Fire drills are not being conducted by sounding
the fire alarm system, only by announcements.



9.6

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

system.
Findings include:

that the elevator penthouse did not have an alarm
notification device as required by Section 9.6.3.2.




Findings include:
The fire alarm system is being tested; however,
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

the report does not conform to requirements set
forth in NFPA 72.




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.



PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)


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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.



PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

installed properly.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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.




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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

Findings include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
Alcohol based hand rub dispensers are

improperly installed over or adjacent to an ignition
source throughout the building.


PRINTED: 07/21/2009
A. BUILDING 01 - SOUTH TOWER, LOWER 9 FLOORS
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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.)


between buildings.
Findings include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.


PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.


PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)



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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

Findings include:

was observed that on the 7th floor, the rated wall
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)


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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)



occupants. 7.10.1.4

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

19.3.7.7

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

Findings include:

was observed that on the 7th floor, the Utility
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

ensure that the travel distances are in accordance
with the Life Safety Code.
Findings Include:



7.1. 19.2.1
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

display exit signs with continuos illumination.
Findings Include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.




Findings Include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.



PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.


PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

9.6

system.
Findings include:

was observed that on the 6th floor, shell space
pull station is not in service.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.




Findings include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
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




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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.




Findings include:
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

Findings include:

was observed that on the 7th floor Electrical
Room a sprinkler is painted.

was observed that on the 6th floor Women's
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.



PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)
(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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)



19.5.2.2

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

Cooking facilities are protected in accordance

with 9.2.3. 19.3.2.6, NFPA 96

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

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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,
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.




Findings Include:

are located.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.



PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

Findings Include:

located.

Penetrations of smoke barriers by ducts are

protected in accordance with 8.3.6.

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.


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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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



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
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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,
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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.
PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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.

PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

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

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.


PRINTED: 07/21/2009
B. WING _____________________________
490024 01/21/2009
ROANOKE, VA 24033

TAG TAG
DEFICIENCY)

State Fire Marshal's Report On Carilion Roanoke Memorial Hospital's Fire Safety Violations

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

State Fire Marshal's Report On Carilion Roanoke Memorial Hospital's Fire Safety Violations

Diunggah oleh

Hak Cipta:

Format Tersedia

PRINTED: 07/21/2009

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

K 000 INITIAL COMMENTS K 000

Description of structure: 10 Story Building

An announced recertification Life Safety Code

The findings that follow demonstrate

If the building has a common wall with a

This STANDARD is not met as evidenced by:

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

K 011 Continued From page 1 K 011

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

On 12/15/2008, at approximately 1000 hours, it

On 12/15/2008, at approximately 1020 hours, it

On 12/17/2008, at approximately 0957 hours, it

On 12/18/2008, at approximately 0940 hours, it

On 12/15/2008, at approximately 1334 hours, it

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

K 011 Continued From page 2 K 011

On 12/15/2008, at approximately 1340 hours, it

These violations have the potential to affect all

The above was witnessed by Department of

Building construction type and height meets one

This STANDARD is not met as evidenced by:

On 12/10/2008, at approximately 1343 hours, it

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

K 012 Continued From page 3 K 012

On 12/15/2008, at approximately 1053 hours, it

On 12/15/2008, at approximately 1314 hours, it

On 12/15/2008, at approximately 1326 hours, it

On 12/15/2008, at approximately 1437 hours, it

On 12/17/2008, at approximately 1023 hours, it

On 12/17/2008, at approximately 1029 hours, it

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

K 012 Continued From page 4 K 012

On 12/17/2008, at approximately 1250 hours, it

On 12/17/2008, at approximately 1431 hours, it

On 12/17/2008, at approximately 1046 hours, it

On 12/17/2008, at approximately 1110 hours, it

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

K 012 Continued From page 5 K 012

On 12/17/2008, at approximately 1121 hours, it

On 12/17/2008, at approximately 1247 hours, it

On 12/17/2008, at approximately 1315 hours, it

On 12/17/2008, at approximately 1324 hours, it

On 12/17/2008, at approximately 1347 hours, it

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

K 012 Continued From page 6 K 012

On 12/17/2008, at approximately 1350 hours, it

On 12/17/2008, at approximately 1423 hours, it

On 12/17/2008, at approximately 1424 hours, it

On 12/17/2008, at approximately 1433 hours, it

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

K 012 Continued From page 7 K 012

On 12/18/2008, at approximately 1450 hours, it

On 12/18/2008, at approximately 1456 hours, it

On 12/18/2008, at approximately 1459 hours, it

On 12/10/2008, at approximately 1342 hours, it

On 12/10/2008, at approximately 1358 hours, it

On 12/15/2008, at approximately 0909 hours, it

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

K 012 Continued From page 8 K 012

On 12/15/2008, at approximately 0912 hours, it