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Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect patients, staff, and visitors by preventing those occupants from readily identifying the path to an available exit from the building during an emergency.

The finding is:

On 02/06/2023, at 2:00pm while accompanied by the DOF, it was observed that the third floor of Building 04 lacks designated directional exit signage at the cross corridors to comply with 39.2.10, and 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 patients, staff, and visitors by preventing those occupants from readily identifying the path to an available exit from the building during an emergency.

The finding is:

On 02/06/2023, at 2:45pm while accompanied by the DOF, it was observed that the first floor of Building 05 lacks designated directional exit signage at the cross corridors to comply with 39.2.10, and 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 patients, staff, and visitors by preventing those occupants from readily identifying the path to an available exit from the building during an emergency.

The finding is:

On 02/07/2023, at 10:00am while accompanied by the DOF, it was observed that the Basement and First floors of Building 06 lack designated directional exit signage at the cross corridors to comply with 18.2.10, and 7.10.1.5.1.

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 from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material and block exiting.

The findings are:

A. On 02/0702023 at 9:35am, while in the company of the MOF, it was observed that the alcove south of Existing OR 5 is used for the storage of combustible materials and is not separated from the means of egress by construction capable of resisting the passage of smoke to comply with Section 19.3.2.1.2 and 8.4.

B. On 02/0702023 at 9:55am, while in the company of the MOF, it was observed that the alcove north of Existing OR 12 is used for the storage of combustible materials and is not separated from the means of egress by construction capable of resisting the passage of smoke to comply with Section 19.3.2.1.2 and 8.4.

Based on observation the facility failed to provide cooking equipment protection in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Failure to provide protection of cooking equipment can compromise the safety of all occupants during a fire/smoke event originating within the cooking facilities.

The finding is:

On February 6, 2023, at 2:45 pm while in the company of the DOF, it was observed that a UL 300 standard Fire Suppression System is not provided at the kitchen as required by 2011 Edition of NFPA 96 and 2009 Edition of NFPA 17A. Staff interview revealed that the facility is in the process of securing a vendor to install a compliant Fire Suppression System at the kitchen.

Based on observation the facility failed to provide required smoke detection protection. This deficient practice can result in failure of the system to operate as intended and delay proper initiation when necessary.

The findings are:

A. On 02/06/2023, at 2:00pm, while in the company of the MOF, it was observed in the MRI Equipment room that ceilnig tile is not cut to fit at penetrations, therefore no complete and continuous physical separation from the room to the ceiling cavity above exists. The missing ceiling material would allow heat and products of combustion to bypass the installed smoke detector and therefore does not comply with NFPA 72-2012, 17.7.3.2.4.2.


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B. On 02/07/2023, at 9:55 am while in the company of the EC, a Smoke Detector was observed near supply/return register at the 1st floor, A Wing Nurse Station that is not in compliance with 2010 Edition of NFPA 72, Section 17.7.4.1.

C. On 02/07/2023, at 10:14 am while in the company of the EC, a Smoke Detector was observed near supply/return register at the 1st floor, C Wing hallway near patient room C126 that is not in compliance with 2010 Edition of NFPA 72, Section 17.7.4.1.

D. On 02/07/2023, at 10:15 am while in the company of the EC, a Smoke Detector was observed near supply/return register at the 1st floor, C Wing Nurse Station that is not in compliance with 2010 Edition of NFPA 72, Section 17.7.4.1.

Based on document review the fire alarm system is not being inspected, tested and maintained in accordance with Code requirements. Failure to properly inspect, test and maintain the fire alarm system can result in failure of the system to operate as intended to warn occupants of a fire/smoke event.

Finding include:

On February 6, 2023, at 1:55 pm while in the company of the EC, it was observed that the documentation for the Semi-annual Fire Alarm System Inspection of the initiating and notifying Fire Alarm devices as required by 2010 Edition of NFPA 72, TBL 14.3.1, was not available for review.

Based on observation the facility failed to correctly separate components for the elevator systems. This deficient practice could affect patients, staff, and visitors, if during a fire event, there is a failure to separate areas dedicated to the function of the elevators, then there is potential for a malfunction or delayed use of the elevators by the fire department.

Findings include:

On 02/07/2023, at 11:00am while accompanied by the DOF, the elevator machine room in Building 06 Basement was observed in use as a place for storage of combustible materials not directly related to the function of the space, and therefore does not comply with Section 9.4.2.2, ANSI/ASME A17.3 2008 edition, section 2.2.1.

Based on observation, the facility failed to install and maintain its piped medical gas system as required. This deficient practice could affect patients, staff, and visitors in the building because the piped medical gas system could fail to operate when needed if not properly installed and maintained.

The finding is:

On 02/06/2023 at 2:00pm, while in the company of the MOF, it was observed that medical gas outlets are in hallways of the ED. This space is open to the medical gas zone valves controls. This installation does not comply with NFPA 99-2012, 5.1.4.8(3).