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Based on observation, not all exit doors are installed or maintained to provide protection of the exit enclosure. This deficiency could affect patients, staff and visitors if the exit access door did not provide the proper protection during a fire emergency.

The finding is:

On November 1, 2022, at 3:05pm, while in the company of the TLPO, on the 4th floor it was observed that the door serving 402 Stair 1 failed to self-latch because the leverset hardware was bent to the extent that the latching mechanism was internally bound and not engaging the strike plate. This does not comply with the requirements of Table 8.3.4.2 and NFPA 80-2010, 6.4.1.1.

Based upon observation, sprinklered hazardous areas are not separated by the minimum construciton standard. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

The finding is:

On November 2, 2022, at 10:30pm while in the company of the TLPO, it was observed on the 2nd floor that Patient Observation Room labeled 2W 421 is used for storage. The door serving the room was observed to be unequipped with fire rated door assembly hardware. This does not comply with 18.3.2.1.

Based on observation and interview, the facility failed to maintain a compliant fire alarm. This deficient practice could affect patients, and staff if the fire alarm system failed to properly notify occupants and first responders of an emergency event.

The finding is:

On November 1, 2022, at 2:00pm it was observed in the company of the SAS that one of the fire alarm control panels showed a "Trouble" code that could not be reset to read "normal". The SAS was aware of the problem and mentioned that this is due to a software update problem. This is not in compliance with compliance with NFPA 72-2010, 10.12., 14.2.1.2.2.

Based on observation the facility failed to maintain sprinkler system as required. Failure to maintain the system could result in delayed response and fire suppression. This deficient practice could affect patients, staff, and visitors during a fire event.

The finding is:

A. On November 1, 2022, at 3:10pm while in the company of the TLPO, it was observed that an escutcheon ring was missing at the sprinkler head in Corridor OB428 near room OB435. This does not comply with NFPA 13-2010, 6.2.7.1.


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B. On 11/1/2022 accompanied by the DFPO, missing and/or damaged ceiling tile were observed. This condition can delay activation of a sprinkler head by allowing heat and combustive materials to bypass the sprinkler. This condition does not comply with NFPA 13-2010, 8.6.4.1. Example locations observed:

1. At 2:16 PM damaged tiles located in G01 Corridor
2. At 2:22 PM missing tiles located in G06 Data Room
3. At 2:39 PM damaged tiles located in G77 Office.
4. At 2:42 PM missing tiles located in G89D Lounge.
5. At 2:48 PM damaged tiles in G93 Work Room.
6. At 3:10 PM missing tiles located in G52 Environmental Service Work Room.

C. On 11/01/2022, while in the company of the DFPO the surveyor observed a missing escutcheon around the annular opening for a concealed sprinkler in the ceiling. This does not comply with NFPA 13-2010, 6.2.7.1. Example locations observed:

1. At 2:16 PM located in the Ground floor Corridor, G01
2. At 2:43 PM located in the Ground floor BioMed Office, G90

Based on record review and interview, it was determined that the facility failed to provide proof of testing of HVAC fire safety devices in accordance with Code requirements. Failure of protective devices during a fire event risk safety of patients, staff and visitors.

The finding is:

On November 2, 2022, at 11:00am while in the company of the TLPO, SAS, and DFO it was determined after document review and staff interview that the most recent fire/smoke damper testing report is dated June 2016 and is therefore expired. Evidence of a fire/smoke damper testing report within the last six years was not provided for the building at time of the survey in accordance with NFPA 80-2010, 9.4 & NFPA 105-2010, 6.5.2.

Based on observation the facility lacks compliant protection of the medical gas piping system. Failure to install and maintain this installation could result in failure of the piping system. This deficient practice could affect patients, staff, and visitors.

The findings are:

On November 1, 2022, while in the company of the TLPO, it was observed that medical gas system piping is supported by a dissimilar metal not in accordance with NFPA 99-2012, 5.1.10.11.4.2. and not otherwise properly insulated to comply with NFPA 99-2012, 5.1.10.11.4.4. Locations include:
A. At 2:15pm above the 7th floor ceiling in Corridor 706B near the centrally located nurses' station
B. At 2:45pm above the 6th floor ceiling in Corridor 606B near the centrally located nurses' station

Based on observation the facility lacks compliant identification of the medical gas piping systems. Failure to label this installation could result in misuse or disruption of medical gas services. This deficient practice could affect patients and staff if services were unexpectantly disrupted.

The finding is:

On November 1, 2022, at 2:45pm while in the company of the TLPO, it was observed above the 6th floor ceiling in Corridor 606B near the centrally located nurses' station that the medical gas piped system is not labeled to identify the content within as stated within NFPA 99-2012, 5.3.11.1.1.

Based on observations and interviews, the facility failed to install and maintain a compliant electrical system. This deficient practice could affect patients, and staff if the emergency power failed to transfer back to normal power due to a transfer switch failure.

Findings include:
A. On November 1, 2022, at 2:50 PM while accompanied by SAS it was determined by visual observations and interview that the labor and delivery "C-Section Room" C1 was not installed with normal power outlets as required by NFPA 70-2011, 517.19.

B. On November 1, 2022, at 3:15 PM while accompanied by SAS it was determined by visual observations and interview that the main operating suite, operating rooms 1, 5, 6 and 7 were not installed with normal power outlets as required by NFPA 70-2011, 517.19.

Based upon observation and staff interview, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

The finding is:

On November 1, 2022, at 9:50am, while in the company of the TLPO, it was observed on the second floor that an electrical receptacle in patient toilet room west of the Soiled Utility room is not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(1).

Based on observation, the facility failed to maintain oxygen storage. This deficient practice could affect patients, staff, and visitors if improperly stored oxygen contributed to a fire.

The finding is:

On 11/02/2022, while accompanied by DFPO, observations revealed freestanding oxygen cylinders, stored unsecured on the floor. This condition is not in accordance with NFPA 99, 11.6.2.3 (11). Example locations observed:

1. At 9:57 AM located in the First Floor ICU Equipment Room, 1N-422
2. At 10:01 AM located in the First Floor MCU Storage Room, 1E-231