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Based upon observation, building separations between Healthcare and non-Healthcare occupancies are not maintained in accordance with Code requirements. Failure to maintain required separations can put occupants at risk to exposure from a fire occuring in the adjacent occupancy.

Findings include:

A. On 4/17/19 while in the company of the DMCE, it was observed that not all doors in the 4-hour barriers separating the non-Healthcare Buildings from the Healthcare Kellogg Building were maintained to self-close to a latched condition to comply with 8.3.3.1 and NFPA 80.

Locations observed include:

1. At 9:40 AM, at the 2nd floor near the West elevators separating the Pavilion Building.

2. At 9:50 AM, at the 1st floor Northwest set of doors, Southwest set of doors, and the Far Southwest set of doors separating the Pavilion Building.

3. At 10:05 AM, at the 1st floor South set of doors separating the Jelke Building.

Based upon observation, not all building structural components are protected to afford the required fire rating. Failure to provide protection can result in premature failure of the building structural components if a fire event occured.

Finding includes:

On 4/17/19 at 3:00 PM while in the company of the PM an unprotected steel beam was observed lacking fire proofing for approximately 3'-0". This condition does not comply with the requirements of 19.1.2.3 as being constructed of materials which maintain a 2-hour fire resistant rating. Location observed: Fifth floor East end of corridor AP-5017 leading to Surgery. Beam is above suspended acoustical tile soffited ceiling.

Based upon observation, means of egress components are not maintained in accordance with Code requirements. Failure to maintain means of egress can compromise the safety of occupants during required exiting of the building.

Findings include:

A. On 4/17/19 at 3:15 PM while in the company of the DMCE it was observed at the 3rd floor exit access door from the tenant suite which serves an occupant load greater than three, that a dead bolt lock was utilized in addition to the lockset, thereby not in compliance with 7.2.1.5.10.6.

B. On 4/17/19 at 3:30 PM while in the company of the DMCE it was observed at the ground floor discharge level of Stair "B" that an interrupter gate was not provided to comply with 7.7.3.4 to prevent occupants from continuing to the lower levels of the building during exiting.

C. On 4/17/19 at 3:35 PM while in the company of the DMCE it was observed at the discharge level of Stair "B" that an Exit Passageway was utilized to reach the exterior door of the building. The Exit Passageway had two tubs identified for shredded paper collection stationed in the Exit Passageway in non-compliance with 7.2.6.1 and 7.1.3.2.3.

Based on observation, not all egress doors are installed and maintained as required. This deficient practice could affect occupants using the egress paths because their egress under emergency conditions could be impeded if they are not properly installed and maintained.

Findings include:

A. On 4/16/19 at 10:35 AM, while in the company of the DMCE, it was observed at the Business occupancy 12th floor south wing that exit signage was not provided to identify access to the second exit from the floor to comply with 39.2.4.1 and 39.2.10.

B. On 4/16/19 at 10:37 AM, while in the company of the DMCE, it was observed that magnetic locking devices where installed on cross corridor doors in the south wing of the 12th floor. The magnets were not active at the time of the inspection but permanent disablement could not be confirmed because components which could become functional appeared to be installed. The doors were not provided with the required signage to comply with 7.2.1.6.1.1(4) in accordance with Delayed Egress locking devices as permitted by 39.2.2.2.5 or sensors and manual release buttons to comply with 7.2.1.6.2(1) & (3) in accordance with Access Controlled Egress systems as permitted by 39.2.2.2.6.

C. On 4/16/19 at 11:15 AM, while in the company of the DMCE, it was observed that Exit signage is provided at doors equipped with magnetic locking devices at the cross corridor doors of the 8th floor Kellogg Node which indicated the Elevator Lobby has exit access into the Peds unit and the Peds unit has exit access to the Elevator Lobby. The Elevator Lobby otherwise has access to at least one exit into the Atrium Building to comply with 7.4.1.6.1. The doors marked as exit access are locked without use of Delayed Egress in compliance with 7.2.1.6.1 as permitted by 19.2.2.2.4(2). The doors are otherwise not in full compliance with 19.2.2.2.5.2(2) because a remote release from the Peds side is not provided from within the locked space.

D. On 4/16/19 at 11:25 AM, while in the company of the DMCE, it was observed that a magnetic locking device was installed on the Business occupancy 7th floor Stair "D" door. The magnets were not active at the time of the inspection but permanent disablement could not be confirmed because components which could become functional appeared to be installed. The doors were not provided with the required signage to comply with 7.2.1.6.1.1(4) in accordance with Delayed Egress locking devices as permitted by 39.2.2.2.5 or sensors and manual release buttons to comply with 7.2.1.6.2(1) & (3) in accordance with Access Controlled Egress systems as permitted by 39.2.2.2.6.

E. On 4/16/19 at 1:40 PM, while in the company of the DMCE, it was observed that a magnetic locking device was installed on the 6th floor Peds Stair "A" door which becomes locked only by the child abduction locking system. The ability to remotely release the lock was indicated not to be provided in accordance with 19.2.2.2.5.2(2) when the door may be locked by the abduction system. Any activation (including by manual pull station) of the fire alarm system was indicated to release the locks, but only activation by sprinkler flow or smoke detection in accordance with 19.2.2.2.5.2(5) is required for the fire alarm system to release the locks.

F. On 4/16/19 at 2:15 PM, while in the company of the DMCE, it was observed that Exit signage is provided to indicate the doors equipped with magnetic locking devices at the cross corridor doors of the 5th floor Kellogg Node are an exit access from the Elevator Lobby into the ED Overflow unit. The Elevator Lobby otherwise has access to at least one other exit into the Atrium Building to comply with 7.4.1.6.1. The doors marked as exit access are locked without use of Delayed Egress in compliance with 7.2.1.6.1 as would be permitted by 19.2.2.2.4(2).

G. On 4/16/19 at 2:35 PM, while in the company of the DMCE, it was observed that the cross corridor doors at the west side of the 5th floor were equipped with magnetic locking devices which provide access to Stair "A". The magnets were not active at the time of the inspection but permanent disablement could not be confirmed because components which could become functional appeared to be installed. The doors were not provided with the required signage to comply with 7.2.1.6.1.1(4) in accordance with Delayed Egress locking devices as permitted by 39.2.2.2.5 or sensors to comply with 7.2.1.6.2(1) in accordance with Access Controlled Egress systems as permitted by 39.2.2.2.6. The doors are otherwise not in full compliance with 19.2.2.2.5.2(2) because a remote release from the ED Overflow side is not provided from within the locked space.

H. On 4/17/19 at 10:35 AM, while in the company of the DMCE, it was observed that magnetic locking devices were installed at the exterior exit doors at the Old North Entry to grade. The installation was provided with the manual release button but lacked the sensor to comply with 7.2.1.6.2(1) as an Access-Controlled Egress door installation.

Based on observation, not all egress doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress under emergency conditions could be impeded if they are not properly installed and maintained.

Findings include:

On 4/16/19, while accompanied by the VPF, observation determined that doors in egress paths, at which no patient special needs exist for specialized protective measures, are secured against egress as prohibited by 19.2.2.2.5.1 because magnetic locks are installed on the indicated door leafs. Locations observed include:

A. At 2:02 PM: 4th Floor cross-corridor door in designated fire/smoke barrier wall, door leaf swinging towards the south.
B. At 2:28 PM: 4th Floor cross-corridor door in fire barrier wall at south end of Bridge, leaf swinging towards the south.

Based on observation, not all stairs or smokeproof enclosures are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained.

Findings include:

A. On 4/16/19 at 10:30 AM, while in the company of the DMCE, it was observed within the Stair "C" enclosure that electrical systems not serving the stair at the 13th & 14th level were identified as serving exterior building signage which does not comply with 7.1.3.2.1(10).

B. On 4/17/19 at 11:05 AM, while in the company of the DMCE, it was observed that the IT Closet at the 1st floor exit passageway at the discharge level of Stair "C" was provided with one door which was only a 20 minute door in lieu of the 90 minute door required by 7.1.3.2.1(9)(c).

Based on observation, not all stairs or smokeproof enclosures are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained.

Findings include:

On 4/16/19, while accompanied by the VPF, observation determined that doors from normally unoccupied areas into exit stairs exist, as prohibited by 7.1.3.2.1(9), because those portions of the indicated building story are vacant construction areas. Locations observed include:

A. At 10:27 AM, 8th Floor South Exit Stair.

B. At 10:34 AM, 8th Floor North Exit Stair.

Based on observation, not all egress paths lead to an exit. This deficient practice could require a person to traverse a longer route to reach an exit. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

Finding includes:

On 4/17/19 at 1:15 PM while accompanied by the PM, corridors were observed which lack designated access to two remote exits and therefore produce dead end conditions which does not comply with 19.2.5.9 and 19.2.5.10.
Location observed: Corridor AP-500C10 North exit leads into the PACU suite.

Based on observation, not all habitable rooms are provided with direct access to a corridor or to the outside as required. This deficient practice could affect patients, staff, and visitors in those rooms because their egress from the building could be impeded if access to a corridor or to the outside is not provided.

Findings include:

On 4/16/19, while accompanied by the VPF, observation determined that egress paths require building occupants to pass through hazardous areas, as prohibited by 7.5.2.1, because those portions of the indicated building story are under construction and contain combustible materials. Locations observed include:

A. At 10:32 AM: 8th Floor egress path from Center Elevator Lobby to South Exit Stair.

B. At 10:33 AM: 8th Floor egress path from Center Elevator Lobby to North Exit Stair.

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the normal power supply. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. On 4/17/19, while in the company of the DMCE, it was observed that typical exit discharge lighting was not of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 7.9.1.3. Locations include:

1. At 11:10 AM at the Exit discharge locations for the 1st floor Administration suite and Stair "C".

2. At 11:15 AM at the Exit discharge exterior stair & path from the Basement level Com Ed Vault area to the south.

Based on observations and staff interview, exit signs are not displayed to define access to at least two means of egress from a floor level to comply with code requirements. Failure to define access to exits can prevent occupants from reaching an alternate exit when the primary exit access is comprised.

Findings includes:

A. On 4/16/19 while in the company of ITDCP, following are the locations not in accordance with Section 7.10.1.8:

1. At 1:30 PM at the 13th floor East side
2. At 1:55 PM at the 12th floor middle patient area near service door
3. At 2:25 PM at th 10th southeast dead end corridor
4. At 2:50 PM at the 8th floor:
a) At Southeast stairwell exit
b) At corridor to Atrium building
c) At the Exterior exit corridor to NICU/Delivery

B. On 4/17/19 while in the company of ITDCP, following are the locations not in accordance with Section 7.10.1.8:

1. At 9:30 AM at the 9th floor north-south corridor
2. At 9:45 AM at the 7th floor east end southeast stair 'C' to PACU
3. At 10:15 AM at the 5th floor east cross corridor
4. At 11:25 AM at the 3rd floor far east north-south exit corridor at double door

Based upon observation, not all exits are provided with "EXIT" signs to identify the exits from the building. Failure to use consistant signage to identify the exits can confuse occupants when locating a means of egress from the building.

Findings include:

On 4/17/19 at 3:20 PM while in the company of the DMCE it was observed on the 3rd floor that "EXIT" signs where utilized to identify exit access and only "STAIRS" signs were provided at the exit stairs. "EXIT" signs are not provided to identify the exit stair access doors to comply with 7.10.3.

Based upon observation, not all exits are provided with "EXIT" signs to identify the exits from the building. Failure to use consistent signage to identify the exits can confuse occupants when locating a means of egress from the building.

Findings include:

A. On 4/17/19 at 1:40 PM while in the company of the DMCE it was observed on the 5th floor that "EXIT" signs where utilized to identify exit access and only "STAIRS" signs were provided at the exit stairs. "EXIT" signs are not provided to identify the exit stair access doors to comply with 7.10.3.

B. On 4/17/19 at 1:50 PM while in the company of the DMCE it was observed within the 510 tenant suite that multiple exam room aisles were provided with exit signage indicating only a single path of means of egress. If this single path were blocked, signs to indicate the alternate path to aisles providing a separate path are not identified to comply with 7.10.1.5.1.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

On 4/17/19 while accompanied by the PM, corridors were observed which lack designated access to two remote exits and therefore produce dead end conditions which does not comply with 7.10 and 19.2.10.1.
Locations observed:

1. At 11:20 AM Clean Corridor AP-500C15 contains one exit sign at the East end of the corridor.
2. At 9:10 AM Corridor AP-500 AA contains one exit sign at the South end of the corridor.

Based on observation, not all vertical openings in the building are protected as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass between building stories if vertical openings are not protected.

Findings include:

On 4/16/19 at 10:02 AM, while accompanied by the VPF, a steel access panel in the floor of the Penthouse was observed to lack a minimum 1-1/2 hour fire rating required by Table 8.3.4.2.

Based on observation the facility failed to maintain compartment separations between floors/areas. This deficient practice could affect patients, staff and visitors to safely reach an exit on a floor level during a fire event on a separate level.

The findings are:

A. On 4/16/19 at 1:20 PM while in the company of the PM an atrium is not separated from the remainder of the building to comply with 8.6.7 (1) (c). Location observed 8th floor On-Call Room AP-884 contains a glass wall which does not comply with 8.6.7(1) (c) (i) and 8.6.7.(1) (c) (ii) for sprinkler protection requirements.

B. On 4/16/19 at 2:45 PM while in the company of the PM a multi-story shaft was observed that is not enclosed in fire rated construction. Location observed: 7th floor shaft located in Equipment Supply AP-710N, contains an access panel which is not labeled or self closing to comply with 19.3.1., and 8.6.5 (1).

C. On 4/17/19 at 9:45 AM while in the company of the PM a 4" diameter conduit penetration is not sealed against fire/smoke. Location observed: 5th floor Electrical room AP- 553UU. This condition does not comply with 19.3.1.1 and 8.6.1.

Based on observation and staff interview hazardous area are not protected in accordance with code requirements. Failure to provide protection of areas with highest degree of hazard than normal to the remaining occupancy can compromise the safety of all occupants during a fire/smoke event originating within the hazardous area.

Finding includes:

On 4/17/19 at 9:45 AM it was observed while in the company of ITDCP, at the 9th floor large mechanical room that a bend in the door created a gap at the meeting stiles of the doors that was not in accordance with 19.3.2.1, 8.7.1.2, 8.4.3.5 and NFPA 80-2010, 6.1,4.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting.

Findings include:

A. On 4/16/19, while in the company of the DMCE, it was observed that sprinklered rooms or spaces used for storage or otherwise defined as Hazardous areas by reference plans were not separated by construction capable of resisting the passage of smoke including self-closing door assemblies to comply with 19.3.2.1, 39.3.2.1, 8.7.1, & 8.4.3.

Locations observed include:

1. On 4/16/19 on the 10th floor at 10:55 AM, the Business occupancy Chute access room 1017B, identified as a Hazardous area, the room door was not self-closing to comply with 39.3.2.1, 8.7.1, & 8.4.3.

2. On 4/17/19 on the 1st floor at 10:00 AM, the Simulation Lab Equipment Storage room 174 pair of 90 minute doors were observed to have a gap at the meeting edges 1/4" or greater in non-compliance with NFPA 80-2010, 6.3.1.7.1.

Based upon observation, sprinklered hazardous areas are not separated by a minimum of smoke resisting construction. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

The findings are:

A. On 4/16/19 at 2:09 PM while accompanied by the PM, the 9th floor Soiled Utility room #910S and Equipment Supply room #910N both indicated on the Life Safety floor plan as having a 1-hour enclosure do not comply with 19.3.2.1 and table 8.3.4.2 due to the following:

1. The entry door's finishes are deteriorated containing delamination and gashes which expose the core.
2. The entry doors are not labeled 3/4 hour.

B. On 4/17/19 at 10:15 AM while accompanied by the PM, a designated hazardous room contains perforated ceiling tile which delays activation of the sprinkler heads. This condition does not comply with 19.3.2.1.2 and 8.4.2 (3) (a). Location observed: 5th floor AP-530SA Medical Waste Room.

Based on observation the facility failed to provide complete smoke detection. This deficient practice could result in the delayed notification of fire/smoke which may affect patients, staff and visitors.

Findings include:

A. On 4/16-17/19 while in the company of ITDCP, the following smoke detectors were found located less than the required distance of 3'-0" from HVAC diffuser, not in accordance with Section 9.6, NFPA 70 and NFPA 72-2010 Edition, Section 17.7.3.1. Location includes:

1. On 4/16/19 at 1:59 PM at the 12th floor look-out point.
2. On 4/17/19 at 2:00 PM at the 3rd floor - Both sides of the double egress door # ETO3FASD69.


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Based on observation during the survey walk through the facility failed to provide protection for the fire alarm components. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

B. On 4/17/19 at 1:50 PM accompanied by the PM, in the 15th floor Mechanical Room (ET-15002), it was observed that the fire alarm Notification Appliance Circuit (NAC) panel located in the North West corner was not provided with smoke detection as require by NFPA 72, 2010, 10.15.

Based on observation, not all fire alarm control functions are installed or operate as required. This deficient practice could affect patients, staff, and visitors in the building because the fire alarm system could fail to operate if its controls are not installed and do not function as required.

Findings include:

A. On 4/16/19, while accompanied by the VPF, observation determined that the following conditions exist in 7th Floor Electrical Closet at Electrical Panel E1-E7A Circuit 20, which serves a fire alarm system NAC Panel:

1. At 11:06 AM: The breaker is not labeled "FIRE ALARM" as required by NFPA 72 2010 10.5.2.2.

2. At 11:07 AM: The breaker is not provided with red marking as required by NFPA 72 2010 10.5.2.3.

B. On 4/16/19 at 11:06 AM, while accompanied by the VPF, observation determined that, in 7th Floor Oxygen Storage Room JB-700T, a fire alarm system NAC Panel is not labeled as to the Electrical Panel and Circuit which feeds it as required by NFPA 72 2010 10.6.5.2.1.

Based on staff interview the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

Findings include:

A. On 4/17/19 at 10:30 AM while in the company of ITDCP, it was observed that the large storage room in the sub-basement adjacent to the pharmacy and gift shop did not have a ceiling or full height wall to separate this space from the above ceiling area of the adjacent pharmacy and gift shop to provide containment of the space to provide effective activation of the sprinkler system to comply with NFPA 13-201-0,4.1 & 3.3.6


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B. On 4/15/19 at 2:00 PM during document review in the company of the MCE the surveyor identified by staff interview the lack of fire sprinkler protection for all of the building's traction elevator machine rooms. NFPA 13, 2010, 8.1.1


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C. On 04/17/2019 at 2:12 PM while in the company of the PM, the 5th floor Operating Room Sterile Core has numerous soffited wall locations containing combustible materials. The current sprinkler layout has a limited distribution and does not comply with NFPA 13 2010, 8.10.6.3 concerning obstructions.

Based on observation, the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

Findings include:

A. On 4/16/19 at 1:10 PM, while in the company of the DMCE, it was observed that the 7th floor east corridor shallow closets which contain storage and structural steel "X" bracing were not provided with sprinkler protection to comply with NFPA 13-2010, 4.1. The smoke detection provided was not mounted at the ceiling to comply with NFPA 72-2010, 17.7.3.2.1.

B. On 4/17/19 at 9:15 AM, while in the company of the DMCE, it was observed that the 3rd floor east corridor shallow IT closets which contain structural steel "X" bracing were not provided with sprinkler protection to comply with NFPA 13-2010, 4.1. The smoke detection provided was not mounted at the ceiling to comply with NFPA 72-2010, 17.7.3.2.1.

C. Areas under construction were observed in the company of the DMCE that are not provided with sprinkler systems installed in full compliance with NFPA 13 due to on-going construction and lack of ceiling systems.

Locations observed include:

1. On 4/16/19 at 10:00 AM at the 13th floor Behavioral Health unit.

2. On 4/16/19 at 2:45 PM at the 4th floor Behavioral Health unit.

3. On 4/17/19 at 9:30 AM at the 2nd floor East Node IT room.

D. On 4/17/19 at 10:10 AM, while in the company of the DMCE it was observed that the 1st floor Electric Panel room within the Simulation Lab area did not have a ceiling to provide containment of the space to provide effective activation of the sprinkler system to comply with NFPA 13-2010, 4.1 & 3.3.6. The smoke detector provided was not at the ceiling/high point of the space to comply with NFPA 72-2010, 17.7.3.2.1.

E. On 4/17/19 at 10:35 AM, while in the company of the DMCE, it was observed that the 1st floor Old North Entry area did not have all ceiling in place to provide containment of the space to provide effective activation of the sprinkler system to comply with NFPA 13-2010, 4.1 & 3.3.6.

F. On 4/17/19 at 10:55 AM, while in the company of the DMCE, it was observed that the 1st floor Fire Alarm Control Panel room did not have all ceiling in place to provide containment of the space to provide effective activation of the sprinkler system to comply with NFPA 13-2010, 4.1 & 3.3.6.


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G. On 4/15/19 at 2:00 PM during document review in the company of the DMCE the surveyor identified by staff interview the lack of fire sprinkler protection for all of the building's traction elevator machine rooms. NFPA 13, 2010, 8.1.1

H. On 4/16/19 at 11:00 AM while accompanied by the PM, it was observed that the facility failed to maintain corridor ceilings in the Basement where the ceiling had not been maintained or had been removed from most of Corridor (KP-000CD) allowing the installed fire sprinklers to be more than 12 inches from the deck above. NFPA 13, 2010, 8.6.4.1

Based on staff interview the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

The finding is:

On 4/15/19 at 2:00 PM during document review in the company of the DMCE the surveyor identified by staff interview the lack of fire sprinkler protection for all of the building's traction elevator machine rooms. NFPA 13, 2010, 8.1.1

Based on staff interview the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

The finding is:

On 4/15/19 at 2:00pm during document review in the company of the MCE the surveyor identified by staff interview the lack of fire sprinkler protection for all of the building's traction elevator machine rooms. NFPA 13, 2010, 8.1.1

Based on observation, the facility failed to inspect, test, and maintain its automatic sprinkler system as required. This deficient practice could affect patients, staff, and visitors in the hospital because the automatic sprinkler system could fail to operate under emergency conditions if it is not properly inspected, tested, and maintained.

Findings include:

On 4/16/19 at 11:09 AM, while accompanied by the VPF, observation determined that, in 7th Floor Patient Sleeping Room JB-707, a sprinkler head is coated with dust as prohibited by NFPA 25 2011 5.2.1.1.2(5).

Based on observation, the facility failed to install and maintain automatic sprinkler protection in accordance with the code requirements. This deficient practice could impair activation of a sprinkler head and delay an emergency response.

Finding includes:

On 4/16/19 at 1:45 PM while accompanied by the PM, sprinkler heads were observed covered with accumulation of lint and dust which does not comply with NFPA 25 2011, 5.2.1.1.2(5).

1. Location observed: Corridor AP-5017

Based on observations and staff interview, spaces open to the exit access corridor are not provided with protective features in accordance with Code requirements. Failure to provide protective features can compromise the use of the corridor when prompt notification of a fire/smoke event occurring within the space open to the exit corridor is not provided.

Findings include:

On 4/16/19 at 2:30 PM while in the company of ITDCP, 8th floor Conference room "A" was not provided with smoke detection to comply with Section 19.3.6.1 (2)(b).

Based on observation, not all use areas are separated from exit access corridors as required. This deficient practice could affect patients, staff, or visitors in the building because smoke or fire could pass from the use areas into the remainder of the building if the use areas are not separated from corridors..

Findings include:

On 4/16/19 at 2:02 PM, while accompanied by the VPF, observation determined that 4th Floor Conference Room JB-405 lacks a smoke detector required by 19.3.6.1(1)(b).

Based on observation, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the area because smoke or fire could move from the separated rooms to the corridor doors are not properly installed and maintained.

Findings include:

On 4/16/19, while accompanied by the VPF, observation determined that the following deficiencies exist at the 4th Floor Conference Room JB-405 Dutch door:

A. At 2:02 PM: Both leafs are not positive latching, including the latching of the upper leaf into the lower leaf, as required by 19.3.6.3.13(1), because a manual throw-bolt is provided from the upper leaf to the lower leaf.

B. At 2:03 PM: The door lacks a rabbet, astragal, or bevel at the meeting edge as required by 19.3.6.3.13(2).

Based on observation, the facility failed to install the ventilation system in the required manner. The deficient practice could affect patients, staff and visitors in the hospital because smoke and fire could be permitted to move between building stories and fire compartments if the system is not properly installed.

Findings include:

On 4/17/19 at 11:15 AM while in the company of ITDCP, four fire dampers penetrating the two hour fire rated wall at the 4th floor east exit corridor were not installed with retaining angles, exposing an opening between the wall and fire damper, not in accordance with Sections 8.3.5.7 and NFPA 90A-2012, 5.4.7.

Based on observation during the survey building tour, the facility failed to isolate and protect ventilation system ducts from other building systems. This deficient practice could affect patients, staff and visitors during a fire event.

Finding is:

On 4/16/19 at 10:30 AM on the 5th floor accompanied by the PM, it was observed that the installation of linen chute (KP-555) within ventilation shaft enclosure (KP-5001) was not separated from supply/return and exhaust duct systems. This is not in compliance with NFPA 90A, 2012, 5.3.4.5.

Based on observation, the facility failed to provide access to fire protection appliances within the ventilation duct system. Failure to install and maintain this installation could result in the passage of fire and products of combustion from one fire compartment to another. This deficient practice could affect patients, staff and visitors during a fire event.

Finding includes:

On 4/17/19 at 2:30 PM while accompanied by the PM, installed access panels located at ductwork, for the inspection and maintenance of fire dampers, lack labeling to identify if the damper is abandoned or active. This condition does not comply with NFPA 80-2010, 19.2.3. Location observed: 7th floor Mechanical room AP-765N

Based upon observation, elevators are not installed and maintained in accordance with Code requirements for Firefighter's Service. Failure to maintain Firefighter's Service can delay availability of the elevators for Firefighter's use during a fire event.

Findings include:

On 4/17/19 at 8:50 AM, while in the company of the DMCE, it was observed that the west public elevator lobby on the 3rd floor has a coffered ceiling in which total bay depth exceeds 12". The north bay lacks smoke detection to comply with NFPA 72-2010, 21.3.5 exception and 17.7.3.2.1.

Based upon observation, Rubbish/Laundry Chutes are not maintained in accordance with Code requirements. Failure to maintain chutes can provide a vertical path for fire and smoke to move to other floors of the building and compromise the safety of other occupants during a fire/smoke emergency.

Findings include:

A. On 4/16/19 at 11:45 AM, while in the company of the DMCE, it was observed that the chute access door of the Rubbish chute on the 8th floor was not self-closing to a latched condition to comply with 19.5.4.1.

B. On 4/16/19 at 2:30 PM, while in the company of the DMCE, it was observed that the chute access door on the 5th floor was not self-closing to a latched condition to comply with 19.5.4.1.

C. On 4/17/19 at 9:30 AM, while in the company of the DMCE, it was observed that the chute access door of the Rubbish chute on the 2nd floor was not self-closing to a latched condition to comply with 19.5.4.1.

D. On 4/17/19 at 11:15 AM, while in the company of the DMCE, it was observed that the Rubbish chute discharge room door at the Basement level was not self-closing to a latched condition to comply with 19.5.4.4 because it rubs on the floor and the latching mechanism is defeated by staff because they don't have a key to the locking door.

E. On 4/17/19 at 1:00 PM, while in the company of the DMCE, it was observed that the 2-hour rated south wing chute discharge room at the Basement level contained ventilation ducts which were not provided with fire dampers to comply with 8.3.5.

Based on observation, not all basic electrical components are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical system could fail to operate properly when needed if the electrical components are not properly installed and maintained.

Findings include:

A. On 4/16/19 at 1:42 PM, while accompanied by the VPF, observation determined that, in 5th Floor Electrical Closet JB-55E, Electrical Panel E2C5A, which is designated as being part of the Critical branch of the building's Type 1 Essential Electrical System, serves emergency lights, required by NFPA 99 2012 6.4.2.2.3.2(1) and NFPA 70 2011 517.32(A) to be served by the Life Safety Branch of that system.

B. On 4/16/19 at 1:48 PM, while accompanied by the VPF, observation determined that the door to the 1st Floor Electrical Switchgear Room lacks an out-swinging door with panic hardware required by NFPA 70 2011 450.43(C).

C. On 4/16/19 at 1:52 PM, while accompanied by the VPF, observation determined that, in the 1st Floor Electrical Closet the electrical panel is not provided with accurate panel directory as required by NFPA 70 2011 408-4(A).

Based on observation, 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.

Finding includes:

On 4/17/19 at 11:15 AM while accompanied by the PM., the surveyor's observation determined that critical care patient beds lack electrical receptacles served by normal power as required by NFPA 70 2011 517-19(A).

1. The location observed: Fifth floor Operating Room # 8.