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From random observation, the surveyor finds that fire separations are not complete between the Mechanical Area located on Level Three, Level Four and Elevator Lobby. These deficiencies could affedct any patients, staff, or visitors in the building by permitting smoke and fire to pass betweeen building stories

A. Third Floor Level (Mechanical Room). The Mechanical Room on the Third Floor was observed open above the Fourth Floor Level. Duct penetrations (2) through the West wall of the Elevator Lobby were observed in a designated two hour fire separation that are not provided with fire dampers to comply with 8.2.3.2.4.1, NFPA 90A 1999 3-3.1.1.

Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

Findings include:

A. The metal lath and plaster membrane of the building's fire rated floor/ceiling assembly or roof ceiling assembly was observed to be removed in several locations, thus compromising the fire resistance capability of the assembly in a manner prohibited by 19.1.6.2. and NFPA 220 1999 Table 3-1. Locations observed include:
1. 1:50 PM October 29, 2013: Fifth Floor Mechanical Room south of Exit Stair C.

2. 2:07 PM October 29, 2013: Fifth Floor Corridor immediately outside the Case Managers' Office.

3. 1:50 PM October 30, 2013, Basement Corridor immediately north of Exit Stair C.

B. At 2:10 PM on October 29, 2013, a series of unprotected steel components were observed at the Fourth Floor of the 1971 Building, which has been gutted for construction purposes, which are thus inconsistent with the building's designated construction type. Structural components observed include, but are not limited to:

1. Steel columns.

2. Steel beams.

3. Open web steel bar joists.

C. At 1:59 PM on October 30, 2013, a wood ceiling structure was observed in the Basement Old Pantry, including wood ceiling joists and wood lath, as prohibited by 19.1.6.2. and NFPA 220 1999.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of separation could result in delayed response to fire/smoke conditions which compromise the facility's use of the exit access corridors.

The finding is:

A. Morning of October 30, 2013 Fifth Floor, Nourishment Area was observed open to an exit access corridor and lacks smoke detection to comply with 19.3.6.1. Exception (1). This Room was indicated with corridor doors on the Life Safety Plan.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to enter the egress corridor.

Findings include:

A. At 2:31 PM on October 30, 2013, the west pair of doors to the Basement Sterile Processing Unit was observed to not be positive latching as required by 19.3.6.3.2.



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A. On the morning of October 31, 2013 First Floor Main Pharmacy corridor door lacks functioning positive latching hardware requred by 19.3.6.3.2.

B. On the morning of October 31, 2013 First Floor Main Pharmacy, the fire shutters in this area are not provided with local smoke detectors required by 19.3.6.3.2.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to enter the egress corridor.

Findings include:

A. Doors in exit access corridors were observed that are not positive latching as required by 19.3.6.3.2. Locations observed include (all Second Floor Same Day Surgery Suite):

1. 9:16 AM October 30, 2013: North pair of opposite swinging doors (near Exit Stair C).

2. 9:20 AM October 30, 2013: Northwest pair of opposite swinging doors (adjacent to South Elevator).

3. 9:24 AM October 30, 2013: West center pair of doors (south of South Elevator).

4. 9:35 AM October 30, 2013: West pair of doors (adjacent to the GI Unit).

Based on random observation during the survey walk-through, not all stair or ventilation shafts or fire rated floor/ceiling assemblies are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between building stories.

A. At 1:54 PM on October 29, 2013, a series of holes were observed, from the Fifth Floor Mechanical Room north of Exit Stair C to the Fourth Floor below, which are not sealed against the passage of fire as required by 8.2.3.2.4.2.

B. At 2:23 PM on October 29, 2013, a duct was observed, visible from the Fourth Floor in the Corridor immediately north of Exit Stair C, which is not provided with a fire damper required by 8.2.3.2.4.1.

C. At 1:49 PM on October 30, 2013, the door to the Freight Elevator adjacent to Exit Stair C was observed to be open, thus connecting multiple building stories in a manner prohibited by 19.3.1.1. and 8.2.5.

D. At 1:57 PM on October 30, 2013, the door to a former ventilation shaft immediately east of the Old Shop was observed to have been removed; thus the shaft connects the Basement to other building stories as prohibited by 19.3.1.1., 8.2.2.2., and 8.2.3.2.3.1(1).

Based on observation the surveyor finds a number of fire dampers that are not installed in accordance with NFPA 90A. Failure to provide and maintain fire rated shaft enclosures and fire dampers at shaft penetrations will allow fire to spread from floor to floor in a fire emergency.

Findings include:

A. Duct penetrations through a designated 2 hour fire resistant walls were observed that, due to the lack of fire damper, would allow the passage of smoke and fire on the Fourth Floor Level. Surveyor observed the ducts extending through Fourth Floor Level. This condition does not comply with NFPA 90A 1999 3-3.2. Location observed:

1. Third Floor - Two ducted grills penetrate through designated 2-hour fire wall were observed on the Fourth Floor Lobby, these ducts originate on the Third Floor of the Boiler Room, and they lack fire dampers.

B. Based on observation, the surveyor finds that vertical openings are not protected in accordance with 8.2. of NFPA 101 - 2000 and/or NFPA 90A - 1999. Location observed include:

1. First Floor, A shaft for sprinkler risers were observed with voids and penetrations through walls that are not fire sealed and with ventilation duct penetration that is not fire sealed and is not installed with retaining angles in accordance with a tested design for fire dampers. This shaft is located next to Stair B and the Medication Office Room.

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. This deficiency could affect any patients, staff, or visitors in the smoke compartments on either side of the cited wall by permitting smoke to pass between them.

Findings include:

A. In the morning of October 30, 2013, pipe and conduit penetrations were observed, in the smoke barrier wall above the cross corridor door and at the back wall of the Nurse Station Fifth Floor, that are not sealed against the passage of smoke as required by 19.3.7.3. and 8.3.6.1.

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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. At 2:35 PM on October 30, 2013, the Linen Room located immediately east of the Sterile Processing Unit was not accessible to Surveyors.


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B. On the afternoon of October 29, 2013, unsealed pipe and other penetrations were observed in the walls of the 6th Floor Soiled Utility Room as prohibited by 19.3.2.1.

C. On the afternoon of October 29, 2013 6th Floor, door label to the Soiled Utility Room across Patient Room 604 is missing to verify the required 3/4 hour fire rating by 19.3.2.1. and 8.2.3.2.3.1(2).

D. On the afternoon of October 29, 2013 6th Floor, the door to Soiled Utility near Room 622 has a latching hardware but does not self-close all the way to latch which does not complies with 8.2.3.2.3.1(2).

E. On the afternoon of October 29, 2013 6th Floor, Door to the Laundry Chute room is not labeled to provide a 3/4 hour fire rating.

F. On the morning of October 30, 2013 5th Floor, Soiled Utility Room, required to be one hour fire enclosed was observed with doors that are not provided with 3/4 hour fire rating to comply with 8.2.3.2.3.1(2). The doors (2) to this room do not carry the required minnimum 3/4 hour fire resistance rating.

G. On the morning of October 31, 2013 First Floor Chart Room 194 A is a hazardous storage area greater than 100 square feet. The door label to this space is painted and lacks self closing hardware.

H. On the morning of October 31, 2013 First Floor, the double doors to Dock Room are propped open.

I. On the afternoon of October 30, 2013 First Floor, the Patient Holding Area for the Cath Lab has been converted to a storage use and is not being fire separated from other areas.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. At 2:30 PM on October 30, 2013, the Basement door to Exit Stair A was observed to lack a label which identifies the door as carrying the minimum 1-1/2 hour fire resistance rating required by 8.2.3.2.3.1(1).


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B. On the afternoon of October 29, 2013, the door to the Exit Stair leading to the Elevator Machine Room on the Penthouse was observed to lack a label which identifies the door as carrying the required 1-1/2 hour fire resistance rating required by 8.2.3.2.3.1(1).

C. On the afternoon of October 29, 2013, a series of pipe penetrations were observed, above the door to the 6th Floor Stairwell A adjacent to Room 611, that are not sealed against the passage of fire as required by 8.2.5.4. and 8.2.3.2.4.2.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. Pipe or other penetrations were observed in exit stair enclosure walls which are not sealed against the passage of fire as required by 8.2.3.2.4.2. Locations observed include (all Fifth Floor):

1. 1:51 PM October 29, 2013: Penetration from Exit Stair C into Mechanical Room to the south.

2. 1:54 PM October 29, 2013: Penetration from Exit Stair C to Mechanical Room to the north.

B. At 1:29 PM on October 30, 2013, the Basement door to Exit Stair D was observed to lack a label which identifies the door as carrying the required 1-1/2 hour fire resistance rating required by 8.2.3.2.3.1(1).

C. At 1:50 PM on October 30, 2013, the Basement door to Exit Stair C was observed to not close to latch as required by 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. At 1:35 PM on October 30, 2013, the guard rails in Exit Stair C were observed to not comply with 7.2.2.4.6(3) because a sphere larger than 4 inches in diameter could pass between the intermediate rails.

B. At 1:48 PM on October 30, 2013, materials were observed being stored in the Basement landing of Exit Stair C, as prohibited by 7.2.2.5.3.

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. At 9:52 AM on October 31, 2013, the path to the exterior exit door at the First Floor landing of Exit Stair A was observed to not be clear, as required by 7.7.3., because the configuration of the exit stair could cause building occupants to continue from the First Floor toward the Basement.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. Exit access corridors were observed at which occupants are directed, by illuminated exit signs, to leave an exit access corridor and pass into a suite of rooms as prohibited by 19.2.5.9. Locations and rooms observed include (all Second Floor, with passage through the Same Day Surgery Suite):

1. 9:16 AM October 30, 2013: North pair of opposite swinging doors (near Exit Stair C).

2. 9:20 AM October 30, 2013: Northwest pair of opposite swinging doors (adjacent to South Elevator).

B. Doors in the means of egress were observed which are identified by illuminated exit signs but which are secured against egress by locking devices as prohibited by 19.2.2.2.4. Locations observed include:

1. 2:20 PM on October 29, 2013: Third Floor Psychiatric Unit.
2. 1:36 PM October 30, 2013: Basement Dining Room sliding gate, which was observed to be capable of being padlocked out of hours.

C. Due to an ongoing construction project, a series of dead end corridors of excessive length were observed as prohibited by 19.2.5.10. Locations observed include:

1. 9:21 AM October 30, 2013: Corridor from northwest pair of doors to the Same Day Surgery Suite (near the South Elevator) toward the north to the "Chicago" Vestibule which separates the 1971 Building from the 1981 Building.

2. 10:15 AM October 30, 2013: Corridor from First Floor Histology Lab (near South Elevator) to the west toward Exit Stair D.

D. At 9:28 AM on October 30, 2013, the Third Floor Corridor from the temporary construction barrier (near the South Elevator) to Exit Stair D was observed to constitute a corridor with a single means of egress as prohibited by 19.2.5.9.

E. At 2:11 PM on October 30, 2013, the door to the Basement Pharmacy was observed to be secured with a latchset and a deadbolt with a thumbturn retractor, thus requiring two operations to open the egress door as prohibited by 7.2.1.5.4.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors attempting to use the egress paths because the paths could become restricted.

Findings include:

A. On the morning of October 31, 2013, First Floor Exit Stair B that continues beyond the level of exit discharge was observed that is not equipped with interrupter gate required by 7.7.3.

B. Not all exit access are arranged so that exits are readily accessible at all times. Locations observed include:

1. On the afternoon of October 30, 2013, Second Floor near the Elevator Lobby an exit sign was observed above the corridor double door which leads exiting through the ICU Suite and does not comply with 7.5.1.2.

2. On the morning of October 30, 2013, First Floor an exit sign was installed in the exit access corridor near the Chart Room 194A that leads exiting through the designated Outpatient Suite.

Based on random observation during the survey walk-through, not all designated or required fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

A. At 2:29 PM on October 30, 2013, the 1-1/2 hour fire rated door to the Basement Linear Accelerator Room was observed to be held open by an unapproved device (a door wedge) as prohibited by 8.2.3.2.1(b) and 7.2.1.8.1.

Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the emergency lighting did not meet all of the requirements of NFPA-101. This could affect all occupants of the building if the emergency lighting does not operate during the loss of normal power.

Findings include:

A. The facility did not have monthly and annual records of the battery light testing as required by NFPA-101, Section 7.9.3.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

A. Doors which, based on their location and the presence of panic hardware may be incorrectly identified by building occupants as part of a means of egress, were observed to lack a sign which reads "NO EXIT" as required by 7.10.8.1. Locations and intervening rooms observed include (all Second Floor, with passage into the Same Day Surgery Suite):

1. 9:16 AM October 30, 2013: North pair of opposite swinging doors (near Exit Stair C).

2. 9:20 AM October 30, 2013: Northwest pair of opposite swinging doors (adjacent to South Elevator).

B. At 2:30 PM on October 29, 2013, the Third Floor door to Exit Stair C was observed to read "STAIR" and not "EXIT" as required by 7.10.1.3.

Based on random observation during the survey walk-through, exit signs did not illuminate a continous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

A. Doors which, based on their location and the presence of panic hardware maybe incorrectly identified by building occupants as part of a means of egress were observed to lack a sign which reads "NO EXIT" as required by 7.10.8.1. Locations observed include:

1. Second Floor- Pair of opposite swinging doors outside the ICU Suite near the Elevator Lobby and Exit Stair B.

2. First Floor - Pair of opposite swinging doors outside the Outpatient Suite near the Elevator Lobby and Exit Stair B.

B. Based on random observation during the survey walk-through, exit signs were not provided or were not fully visible to designate the path of egress in all cases in accordance with 19.2.10.1. and 7.10. Locations observed include:

1. Second Floor O.R.- Designated exit sign reads "STAIR" and not "EXIT" to comply with 7.10.1.3. Locations observed include:

a. Exit Stair A at the back of O.R. exit access corridor.

C. On the afternoon of October 30, 2013 Second Floor O.R., The surveyor observed the exit access corridor outside O.R. #4 lacks an exit sign to comply with 7.10.1.1.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. These deficiencies could affect any patients, staff, or visitors in the building because the staff may not be properly prepared for a fire emergency.

Findings include:

A. Based on document review conducted at 11:30 AM on October 30, 2013, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2012 and 2013, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. First Shift:

a. January 19, 2012: 10:30 AM.

b. June 3, 2012: 10:30 AM.

c. July 20, 2012: 10:30 AM.

d. October 5, 2012: 10:30 AM.

e. January 16, 2013: 10:30 AM.

f. May 2, 2013: 10:30 AM.

g. July 25, 2013: 10:30 AM.

2. Second Shift:

a. February 21, 2012: 9:30 PM.

b. May 9, 2012: 9:30 PM.

c. August 12, 2012: 9:30 PM.

d. November 30, 2012: 9:30 PM.

e. January 23, 2013: 9:30 PM.

f. June 1, 2013: 9:30 PM.

g. August 2, 2013: 9:30 PM.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. These deficiencies could affect any patients, staff, or visitors in theareas of the deficiencies cited becasue the activation of or response to the building fire alarm system could be delayed.

Findings include:

A. At 11:13 AM on October 31, 2013, the fire alarm manual pull station at the Fifth Floor door to Exit Stair B was observed to be more than 5'-0" from the door as required by 9.6.2.3. and NFPA 72 1999 2-8.2.2., because it is located across the Corridor from the Exit Stair.

B. At 11:16 AM on October 31, 2012, the fire alarm system audible alarm was not at least 10 dBA above the ambient noise level, as required by 9.6.3.8. and NFPA 72 1999 4-3.3.2., in the east portion of the Fifth Floor North East-West Corridor.


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C. Smoke detectors were observed that are located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1. Locations observed include:

1. On the afternoon of October 30, 2013, Second Floor Elevator Lobby, a smoke detector was observed that is located within 3'-0" of supply air diffuser.

2. On the afternoon of October 30, 2013, Second Floor O.R., a smoke detector was observed too close to a diffuser.

3. On the afternoon of October 30, 2013, First Floor Primary Care hallway a smoke detector was observed too close to a diffuser.

D. Based on observation during fire alarm testing on the morning of October 31, 2013. The surveyor notes that the double doors to the POB with automatic open function did not disable during activation of the system.


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E. The main fire alarm panels, the NAC panels, and the duct detector panels were located in unmanned locations and the rooms where panels were located were not equipped with smoke detectors as required by NFPA-72, Section 1-5.6.

F. The fourth floor north elevator lobby was not equipped with a fire alarm audible or visual fire alarm device and did not meet the requirements of NFPA-72, Section 4-3.2.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the automatic sprinkler system may not cover the area of the fire.

Findings include:

A. At 10:13 AM on October 30, 2013, the sprinkler heads in the First Floor Medical Records Room were observed to be obstructed by rolling file units as prohibited by NFPA 13 1999 5-6.5.

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed and maintained in accordance with NFPA-13 (1999).

Findings include:

A. On the morning of October 28, 2013 Sixth Floor, Janitor's Closet. The inspector's test drain was observed that is not installed with a 1/2 inch orifice at the drain as required by NFPA 13.

B. On the morning of October 30, 2013, Fifth Floor, Closet (Elec/Data) has an exposed deck and the sprinkler head was installed more than 12" from the floor above and compromises sprinkler protection.

C. On the morning of October 30, 2013, Third Floor -Toilet Room near the Engineering Offices was observed with a sprinkler head that is being painted.

D. Rooms or spaces within designated sprinklered smoke compartments were observed that lack sprinkler heads required by NFPA 13 1999 5-1.1.(1). Locations observed include:

1. Second Floor Voice / Data Closets by the Elevator Lobby.

Based on document review and interview with the Director of Facilities and Director of Engineering it could not be determined that the fire pump is tested annually under emergency power. (NFPA 25, 1998, 5-3.3.4.)

Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the fire pump installation did not meet all of the requirements of NFPA-20. This could affect all occupants of the building if the fire pump does not operate during fire emergency.

Findings include:

A. The fire pump was not equipped with the four required alarm points as required by NFPA-20, Section 7-4.7: a) loss of phase, b) pump running, c) phase reversal, and d) connected to emergency source of power.

Based upon observation fire extinguishers provided are not maintained in accordance with NFPA 10. These deficiencies could affect any patients, staff, or visitors in the area because the ability to provide an immediate ersponse to a fire couild be compromised. Locations observed include:

A. On the afternoon of October 30, 2013 Second Floor O.R., the surveyor observed the fire extinguisher tag located in the Sterile Area lacks the inspection maintenace which is required every 30 days to comply with NFPA 10 1998 4-3.1.

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the area of the cited deficiencies because smoke and fire could pass between building stories.

Findings include:

A. At 2:45 PM on October 29, 2013, the following deficiencies were observed at the ventilation shaft accessed from inside the Third Floor Psychiatric Unit Staff Lounge:

1. A duct penetration through the west wall of 2 hour fire rated ventilation shaft was observed which lack a fire damper required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1.

2. Pipe or other penetrations in the west wall of the ventilation shaft were observed which are not sealed against the passage of fire as required by 8.2.3.2.4.2.

Based on random observation during the survey walk-through, staff interview, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the immediate area because fire could be permitted to pass between building stories.

Findings include:

A. On the afternoon of October 29, 2013, 6th Floor ventilation shaft corridor wall adjacent to SW Stair was observed with ducts and installed fire dampers. The ducts are not installed with retaining angles in accordance with a tested design for fire dampers.

B. On the morning of October 30, 2013, Third Floor, designated two hour fire rated wall between the Mechanical Room and the Engineering Office vestibule was observed with duct penetration that is not fire dampered.

C. On the morning of October 30, 2013, Third Floor, the designated two hour fire separation wall near the Director of Facilities office was observed with a non self-closing and a non rated door which is required to be 1 1/2 fire rated.

D. On the afternoon of October 30, 2013, Second Floor O.R. Based upon observation and based upon staff interview, the surveyor finds that the fire damper installed for the duct located above the ceiling of the Decontamination Room was not maintained and tested since 08/19/03.

A. ased on direct observation the afternoon of 10/30/13 while in the company of Chief Engineer, the surveyor finds the facility failed to maintain the manual means for activating the kitchen hood fire suppression system. The manual pull station was hanging loose from the ceiling and not supported from a stable surface.

B Based on direct observation the afternoon of 10/30/13 while in the company of Chief Engineer, the surveyor finds the facility failed to provide a "Class K" portable fire extinguisher for the cafeteria cooking area.

6th Floor:
By direct observation the morning of 10/30/13 while in the company of Chief Engineer, the surveyor finds the linen chute door is not maintained to be self closing. This will allow products of combustion (i.e. fire and smoke) to escape to the interior of the building and not be contained to the chute itself.


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Based on observation the Linen Chute was not provided by fire resistive construction with a fire door assembly. This deficiency could affect any patients, staff, or visitors in the area because fire and smoke could pass through an improperly rated chute door.

Findings include:

A. On the morning of October 31, 2013 First Floor, the surveyor observed the door label to the Linen Chute Room discharge was painted.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

A. At 1:46 PM on October 30, 2013, carts and equipment were observed, in the basement Corridor immediately west of Exit Stair C (and immediately north of the door to the Kitchen) which obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1.

Based on random observation during the walk-through, the surveyor observed that exit access corridors were obstructed and are not maintained in accordance with 7.1.10 and 19.3.6.1. Failure to maintain the means of egress will delay movement or evacuation in an emergency.

Findings include:

A. On the afternoon of October 30, 2013 Second Floor Cath Lab Area. The aisle was obstructed by medical carts.

Based on random observation during the survey walk-through, not all medical gas piping systems are installed and maintained in accordance with NFPA 99. These deficiencies could affect any patients in the cited area becasue the medical gas system could become compromised.

A. At 9:23 AM on October 30, 2013, the manual medical gas zone (shut-off) valves serving the northeast set of Second Floor Same Day Surgery Prep/Recovery Bays were observed to be located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d).

Based on direct observation the morning of 10/30/13 while in the company of Chief Engineer, the surveyor finds the facility failed to maintain the medical air compressor intake per NFPA 99, 1999, 4-3.1.1.9. (b). The screen cover for the intake needs repair and cleaning. These deficiencies allow for possible contamination of the breathable medical air system and putting patients at risk needing respiratory assistance.


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Based on direct observation, the surveyor finds the facility failed to provide separation by an intervening wall between the medical gas zone valves and the outlets they serve to comply with NFPA 99, 1999, 4-3.1.2.3 (d). These deficiencies could pose a potential hazard to patients if medical gas zone valves are not installed properly in accordance with NFPA 99.

A. On the afternoon of October 30, 2013, by direct observation the surveyor finds that not all medical gas zone valves are separated from the outlets/inlets they serve. This does not comply with NFPA 99, 1999, 4-3.1.2.3. Locations observed:

1. First Floor, Cath Lab Suite in the Patient Holding area.

Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the generator installation did not meet all of the requirements of NFPA-110. This could affect all occupants of the building if the generator does not operate during the loss of normal power.

Findings include:

A. The generator was not equipped with a remote manual stop station in accordance with NFPA-110, Section 3-5.5.6.

B. The facility's remote annunciator was not located at a location that was staffed 24/7 as required by NFPA-99, Section 3-4.1.1.15.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.


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Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the elevator installation did not meet all of the requirements of ANSI/ASME A17.3. This could affect all occupants of the building if the elevators do not operate properly during an emergency.

Findings include:

B. The elevator equipment room was equipped with sprinklers, but there was not a heat detector located within 2' of each sprinkler head, and there was no means to automatically disconnect the main power supply to the elevator prior to application of water in the machine room or shaft as required by ASME 17.1, Section 102.2.c.3.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. Panels LP-LL, and Panel ESS2 in the main electrical room had mixed loads that were not separated into the proper emergency branches as required by NFPA-70, Section 517-32 through 517-34.

Based on random observation with the O.R. Manager and the Maintenance Technician present the surveyor finds that electrical installations and materials do not comply with NFPA 70-1999:

Findings include:

A. On the morning of October 30, 2013, Second Floor O.R., Electrical Panels located on the corridor near the Sterile Storage Room were observed to being blocked with medical carts and the required 3'-0" clearance is not being maintained in front of the panels.


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Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect any patient undergoing surgery if the transfer switch serving the operating rooms fails.

Findings include:

B. The operating rooms were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect any occupant of the building using the elevator during a power outage.

Findings include:

A. The cab lighting for the hydraulic elevator was fed from a normal power panel 3NPB, rather than a life safety panel as required by NFPA-70, Section 517-32.

B. The electric panel in the kitchen near the hood ansul system was missing a directory as required by NFPA-70, Section 110-22. Several panel directories throughout the facility needed updating.

Based on staff interview, interim life safety and other required measures are not implemented when the building fire alarm system is out of service for more than 4 hours in a 24 hour period as required by 9.6.1.8. These deficiencies could affect any patients, staff, or visitors in the building

Findings include:

A. During a test of the building fire alarm system conducted on the morning of October 31, 2013, it was determined that portions of the system had been disabled by contractor forces. During an interview held at 11:45 AM on that date, the provider's Director of Facilities confirmed that the following steps required by 9.6.1.8. had not occurred as a result of the fire alarm system shutdown:

1. No fire watch was implemented while the portions of the fire alarm system was disabled.

2. The Authority Having Jurisdiction was not advised of the partial fire alarm system shutdown.

From random observation, the surveyor finds that fire separations are not complete between the Mechanical Area located on Level Three, Level Four and Elevator Lobby. These deficiencies could affedct any patients, staff, or visitors in the building by permitting smoke and fire to pass betweeen building stories

A. Third Floor Level (Mechanical Room). The Mechanical Room on the Third Floor was observed open above the Fourth Floor Level. Duct penetrations (2) through the West wall of the Elevator Lobby were observed in a designated two hour fire separation that are not provided with fire dampers to comply with 8.2.3.2.4.1, NFPA 90A 1999 3-3.1.1.

Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

Findings include:

A. The metal lath and plaster membrane of the building's fire rated floor/ceiling assembly or roof ceiling assembly was observed to be removed in several locations, thus compromising the fire resistance capability of the assembly in a manner prohibited by 19.1.6.2. and NFPA 220 1999 Table 3-1. Locations observed include:
1. 1:50 PM October 29, 2013: Fifth Floor Mechanical Room south of Exit Stair C.

2. 2:07 PM October 29, 2013: Fifth Floor Corridor immediately outside the Case Managers' Office.

3. 1:50 PM October 30, 2013, Basement Corridor immediately north of Exit Stair C.

B. At 2:10 PM on October 29, 2013, a series of unprotected steel components were observed at the Fourth Floor of the 1971 Building, which has been gutted for construction purposes, which are thus inconsistent with the building's designated construction type. Structural components observed include, but are not limited to:

1. Steel columns.

2. Steel beams.

3. Open web steel bar joists.

C. At 1:59 PM on October 30, 2013, a wood ceiling structure was observed in the Basement Old Pantry, including wood ceiling joists and wood lath, as prohibited by 19.1.6.2. and NFPA 220 1999.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of separation could result in delayed response to fire/smoke conditions which compromise the facility's use of the exit access corridors.

The finding is:

A. Morning of October 30, 2013 Fifth Floor, Nourishment Area was observed open to an exit access corridor and lacks smoke detection to comply with 19.3.6.1. Exception (1). This Room was indicated with corridor doors on the Life Safety Plan.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to enter the egress corridor.

Findings include:

A. At 2:31 PM on October 30, 2013, the west pair of doors to the Basement Sterile Processing Unit was observed to not be positive latching as required by 19.3.6.3.2.



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A. On the morning of October 31, 2013 First Floor Main Pharmacy corridor door lacks functioning positive latching hardware requred by 19.3.6.3.2.

B. On the morning of October 31, 2013 First Floor Main Pharmacy, the fire shutters in this area are not provided with local smoke detectors required by 19.3.6.3.2.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to enter the egress corridor.

Findings include:

A. Doors in exit access corridors were observed that are not positive latching as required by 19.3.6.3.2. Locations observed include (all Second Floor Same Day Surgery Suite):

1. 9:16 AM October 30, 2013: North pair of opposite swinging doors (near Exit Stair C).

2. 9:20 AM October 30, 2013: Northwest pair of opposite swinging doors (adjacent to South Elevator).

3. 9:24 AM October 30, 2013: West center pair of doors (south of South Elevator).

4. 9:35 AM October 30, 2013: West pair of doors (adjacent to the GI Unit).

Based on random observation during the survey walk-through, not all stair or ventilation shafts or fire rated floor/ceiling assemblies are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between building stories.

A. At 1:54 PM on October 29, 2013, a series of holes were observed, from the Fifth Floor Mechanical Room north of Exit Stair C to the Fourth Floor below, which are not sealed against the passage of fire as required by 8.2.3.2.4.2.

B. At 2:23 PM on October 29, 2013, a duct was observed, visible from the Fourth Floor in the Corridor immediately north of Exit Stair C, which is not provided with a fire damper required by 8.2.3.2.4.1.

C. At 1:49 PM on October 30, 2013, the door to the Freight Elevator adjacent to Exit Stair C was observed to be open, thus connecting multiple building stories in a manner prohibited by 19.3.1.1. and 8.2.5.

D. At 1:57 PM on October 30, 2013, the door to a former ventilation shaft immediately east of the Old Shop was observed to have been removed; thus the shaft connects the Basement to other building stories as prohibited by 19.3.1.1., 8.2.2.2., and 8.2.3.2.3.1(1).

Based on observation the surveyor finds a number of fire dampers that are not installed in accordance with NFPA 90A. Failure to provide and maintain fire rated shaft enclosures and fire dampers at shaft penetrations will allow fire to spread from floor to floor in a fire emergency.

Findings include:

A. Duct penetrations through a designated 2 hour fire resistant walls were observed that, due to the lack of fire damper, would allow the passage of smoke and fire on the Fourth Floor Level. Surveyor observed the ducts extending through Fourth Floor Level. This condition does not comply with NFPA 90A 1999 3-3.2. Location observed:

1. Third Floor - Two ducted grills penetrate through designated 2-hour fire wall were observed on the Fourth Floor Lobby, these ducts originate on the Third Floor of the Boiler Room, and they lack fire dampers.

B. Based on observation, the surveyor finds that vertical openings are not protected in accordance with 8.2. of NFPA 101 - 2000 and/or NFPA 90A - 1999. Location observed include:

1. First Floor, A shaft for sprinkler risers were observed with voids and penetrations through walls that are not fire sealed and with ventilation duct penetration that is not fire sealed and is not installed with retaining angles in accordance with a tested design for fire dampers. This shaft is located next to Stair B and the Medication Office Room.

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. This deficiency could affect any patients, staff, or visitors in the smoke compartments on either side of the cited wall by permitting smoke to pass between them.

Findings include:

A. In the morning of October 30, 2013, pipe and conduit penetrations were observed, in the smoke barrier wall above the cross corridor door and at the back wall of the Nurse Station Fifth Floor, that are not sealed against the passage of smoke as required by 19.3.7.3. and 8.3.6.1.

.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. At 2:35 PM on October 30, 2013, the Linen Room located immediately east of the Sterile Processing Unit was not accessible to Surveyors.


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B. On the afternoon of October 29, 2013, unsealed pipe and other penetrations were observed in the walls of the 6th Floor Soiled Utility Room as prohibited by 19.3.2.1.

C. On the afternoon of October 29, 2013 6th Floor, door label to the Soiled Utility Room across Patient Room 604 is missing to verify the required 3/4 hour fire rating by 19.3.2.1. and 8.2.3.2.3.1(2).

D. On the afternoon of October 29, 2013 6th Floor, the door to Soiled Utility near Room 622 has a latching hardware but does not self-close all the way to latch which does not complies with 8.2.3.2.3.1(2).

E. On the afternoon of October 29, 2013 6th Floor, Door to the Laundry Chute room is not labeled to provide a 3/4 hour fire rating.

F. On the morning of October 30, 2013 5th Floor, Soiled Utility Room, required to be one hour fire enclosed was observed with doors that are not provided with 3/4 hour fire rating to comply with 8.2.3.2.3.1(2). The doors (2) to this room do not carry the required minnimum 3/4 hour fire resistance rating.

G. On the morning of October 31, 2013 First Floor Chart Room 194 A is a hazardous storage area greater than 100 square feet. The door label to this space is painted and lacks self closing hardware.

H. On the morning of October 31, 2013 First Floor, the double doors to Dock Room are propped open.

I. On the afternoon of October 30, 2013 First Floor, the Patient Holding Area for the Cath Lab has been converted to a storage use and is not being fire separated from other areas.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. At 2:30 PM on October 30, 2013, the Basement door to Exit Stair A was observed to lack a label which identifies the door as carrying the minimum 1-1/2 hour fire resistance rating required by 8.2.3.2.3.1(1).


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B. On the afternoon of October 29, 2013, the door to the Exit Stair leading to the Elevator Machine Room on the Penthouse was observed to lack a label which identifies the door as carrying the required 1-1/2 hour fire resistance rating required by 8.2.3.2.3.1(1).

C. On the afternoon of October 29, 2013, a series of pipe penetrations were observed, above the door to the 6th Floor Stairwell A adjacent to Room 611, that are not sealed against the passage of fire as required by 8.2.5.4. and 8.2.3.2.4.2.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. Pipe or other penetrations were observed in exit stair enclosure walls which are not sealed against the passage of fire as required by 8.2.3.2.4.2. Locations observed include (all Fifth Floor):

1. 1:51 PM October 29, 2013: Penetration from Exit Stair C into Mechanical Room to the south.

2. 1:54 PM October 29, 2013: Penetration from Exit Stair C to Mechanical Room to the north.

B. At 1:29 PM on October 30, 2013, the Basement door to Exit Stair D was observed to lack a label which identifies the door as carrying the required 1-1/2 hour fire resistance rating required by 8.2.3.2.3.1(1).

C. At 1:50 PM on October 30, 2013, the Basement door to Exit Stair C was observed to not close to latch as required by 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. At 1:35 PM on October 30, 2013, the guard rails in Exit Stair C were observed to not comply with 7.2.2.4.6(3) because a sphere larger than 4 inches in diameter could pass between the intermediate rails.

B. At 1:48 PM on October 30, 2013, materials were observed being stored in the Basement landing of Exit Stair C, as prohibited by 7.2.2.5.3.

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. At 9:52 AM on October 31, 2013, the path to the exterior exit door at the First Floor landing of Exit Stair A was observed to not be clear, as required by 7.7.3., because the configuration of the exit stair could cause building occupants to continue from the First Floor toward the Basement.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. Exit access corridors were observed at which occupants are directed, by illuminated exit signs, to leave an exit access corridor and pass into a suite of rooms as prohibited by 19.2.5.9. Locations and rooms observed include (all Second Floor, with passage through the Same Day Surgery Suite):

1. 9:16 AM October 30, 2013: North pair of opposite swinging doors (near Exit Stair C).

2. 9:20 AM October 30, 2013: Northwest pair of opposite swinging doors (adjacent to South Elevator).

B. Doors in the means of egress were observed which are identified by illuminated exit signs but which are secured against egress by locking devices as prohibited by 19.2.2.2.4. Locations observed include:

1. 2:20 PM on October 29, 2013: Third Floor Psychiatric Unit.
2. 1:36 PM October 30, 2013: Basement Dining Room sliding gate, which was observed to be capable of being padlocked out of hours.

C. Due to an ongoing construction project, a series of dead end corridors of excessive length were observed as prohibited by 19.2.5.10. Locations observed include:

1. 9:21 AM October 30, 2013: Corridor from northwest pair of doors to the Same Day Surgery Suite (near the South Elevator) toward the north to the "Chicago" Vestibule which separates the 1971 Building from the 1981 Building.

2. 10:15 AM October 30, 2013: Corridor from First Floor Histology Lab (near South Elevator) to the west toward Exit Stair D.

D. At 9:28 AM on October 30, 2013, the Third Floor Corridor from the temporary construction barrier (near the South Elevator) to Exit Stair D was observed to constitute a corridor with a single means of egress as prohibited by 19.2.5.9.

E. At 2:11 PM on October 30, 2013, the door to the Basement Pharmacy was observed to be secured with a latchset and a deadbolt with a thumbturn retractor, thus requiring two operations to open the egress door as prohibited by 7.2.1.5.4.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors attempting to use the egress paths because the paths could become restricted.

Findings include:

A. On the morning of October 31, 2013, First Floor Exit Stair B that continues beyond the level of exit discharge was observed that is not equipped with interrupter gate required by 7.7.3.

B. Not all exit access are arranged so that exits are readily accessible at all times. Locations observed include:

1. On the afternoon of October 30, 2013, Second Floor near the Elevator Lobby an exit sign was observed above the corridor double door which leads exiting through the ICU Suite and does not comply with 7.5.1.2.

2. On the morning of October 30, 2013, First Floor an exit sign was installed in the exit access corridor near the Chart Room 194A that leads exiting through the designated Outpatient Suite.

Based on random observation during the survey walk-through, not all designated or required fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

A. At 2:29 PM on October 30, 2013, the 1-1/2 hour fire rated door to the Basement Linear Accelerator Room was observed to be held open by an unapproved device (a door wedge) as prohibited by 8.2.3.2.1(b) and 7.2.1.8.1.

Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the emergency lighting did not meet all of the requirements of NFPA-101. This could affect all occupants of the building if the emergency lighting does not operate during the loss of normal power.

Findings include:

A. The facility did not have monthly and annual records of the battery light testing as required by NFPA-101, Section 7.9.3.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

A. Doors which, based on their location and the presence of panic hardware may be incorrectly identified by building occupants as part of a means of egress, were observed to lack a sign which reads "NO EXIT" as required by 7.10.8.1. Locations and intervening rooms observed include (all Second Floor, with passage into the Same Day Surgery Suite):

1. 9:16 AM October 30, 2013: North pair of opposite swinging doors (near Exit Stair C).

2. 9:20 AM October 30, 2013: Northwest pair of opposite swinging doors (adjacent to South Elevator).

B. At 2:30 PM on October 29, 2013, the Third Floor door to Exit Stair C was observed to read "STAIR" and not "EXIT" as required by 7.10.1.3.

Based on random observation during the survey walk-through, exit signs did not illuminate a continous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

A. Doors which, based on their location and the presence of panic hardware maybe incorrectly identified by building occupants as part of a means of egress were observed to lack a sign which reads "NO EXIT" as required by 7.10.8.1. Locations observed include:

1. Second Floor- Pair of opposite swinging doors outside the ICU Suite near the Elevator Lobby and Exit Stair B.

2. First Floor - Pair of opposite swinging doors outside the Outpatient Suite near the Elevator Lobby and Exit Stair B.

B. Based on random observation during the survey walk-through, exit signs were not provided or were not fully visible to designate the path of egress in all cases in accordance with 19.2.10.1. and 7.10. Locations observed include:

1. Second Floor O.R.- Designated exit sign reads "STAIR" and not "EXIT" to comply with 7.10.1.3. Locations observed include:

a. Exit Stair A at the back of O.R. exit access corridor.

C. On the afternoon of October 30, 2013 Second Floor O.R., The surveyor observed the exit access corridor outside O.R. #4 lacks an exit sign to comply with 7.10.1.1.

Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. These deficiencies could affect any patients, staff, or visitors in the building because the staff may not be properly prepared for a fire emergency.

Findings include:

A. Based on document review conducted at 11:30 AM on October 30, 2013, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2012 and 2013, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. First Shift:

a. January 19, 2012: 10:30 AM.

b. June 3, 2012: 10:30 AM.

c. July 20, 2012: 10:30 AM.

d. October 5, 2012: 10:30 AM.

e. January 16, 2013: 10:30 AM.

f. May 2, 2013: 10:30 AM.

g. July 25, 2013: 10:30 AM.

2. Second Shift:

a. February 21, 2012: 9:30 PM.

b. May 9, 2012: 9:30 PM.

c. August 12, 2012: 9:30 PM.

d. November 30, 2012: 9:30 PM.

e. January 23, 2013: 9:30 PM.

f. June 1, 2013: 9:30 PM.

g. August 2, 2013: 9:30 PM.

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. These deficiencies could affect any patients, staff, or visitors in theareas of the deficiencies cited becasue the activation of or response to the building fire alarm system could be delayed.

Findings include:

A. At 11:13 AM on October 31, 2013, the fire alarm manual pull station at the Fifth Floor door to Exit Stair B was observed to be more than 5'-0" from the door as required by 9.6.2.3. and NFPA 72 1999 2-8.2.2., because it is located across the Corridor from the Exit Stair.

B. At 11:16 AM on October 31, 2012, the fire alarm system audible alarm was not at least 10 dBA above the ambient noise level, as required by 9.6.3.8. and NFPA 72 1999 4-3.3.2., in the east portion of the Fifth Floor North East-West Corridor.


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C. Smoke detectors were observed that are located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1. Locations observed include:

1. On the afternoon of October 30, 2013, Second Floor Elevator Lobby, a smoke detector was observed that is located within 3'-0" of supply air diffuser.

2. On the afternoon of October 30, 2013, Second Floor O.R., a smoke detector was observed too close to a diffuser.

3. On the afternoon of October 30, 2013, First Floor Primary Care hallway a smoke detector was observed too close to a diffuser.

D. Based on observation during fire alarm testing on the morning of October 31, 2013. The surveyor notes that the double doors to the POB with automatic open function did not disable during activation of the system.


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E. The main fire alarm panels, the NAC panels, and the duct detector panels were located in unmanned locations and the rooms where panels were located were not equipped with smoke detectors as required by NFPA-72, Section 1-5.6.

F. The fourth floor north elevator lobby was not equipped with a fire alarm audible or visual fire alarm device and did not meet the requirements of NFPA-72, Section 4-3.2.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the automatic sprinkler system may not cover the area of the fire.

Findings include:

A. At 10:13 AM on October 30, 2013, the sprinkler heads in the First Floor Medical Records Room were observed to be obstructed by rolling file units as prohibited by NFPA 13 1999 5-6.5.

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed and maintained in accordance with NFPA-13 (1999).

Findings include:

A. On the morning of October 28, 2013 Sixth Floor, Janitor's Closet. The inspector's test drain was observed that is not installed with a 1/2 inch orifice at the drain as required by NFPA 13.

B. On the morning of October 30, 2013, Fifth Floor, Closet (Elec/Data) has an exposed deck and the sprinkler head was installed more than 12" from the floor above and compromises sprinkler protection.

C. On the morning of October 30, 2013, Third Floor -Toilet Room near the Engineering Offices was observed with a sprinkler head that is being painted.

D. Rooms or spaces within designated sprinklered smoke compartments were observed that lack sprinkler heads required by NFPA 13 1999 5-1.1.(1). Locations observed include:

1. Second Floor Voice / Data Closets by the Elevator Lobby.

Based on document review and interview with the Director of Facilities and Director of Engineering it could not be determined that the fire pump is tested annually under emergency power. (NFPA 25, 1998, 5-3.3.4.)

Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the fire pump installation did not meet all of the requirements of NFPA-20. This could affect all occupants of the building if the fire pump does not operate during fire emergency.

Findings include:

A. The fire pump was not equipped with the four required alarm points as required by NFPA-20, Section 7-4.7: a) loss of phase, b) pump running, c) phase reversal, and d) connected to emergency source of power.

Based upon observation fire extinguishers provided are not maintained in accordance with NFPA 10. These deficiencies could affect any patients, staff, or visitors in the area because the ability to provide an immediate ersponse to a fire couild be compromised. Locations observed include:

A. On the afternoon of October 30, 2013 Second Floor O.R., the surveyor observed the fire extinguisher tag located in the Sterile Area lacks the inspection maintenace which is required every 30 days to comply with NFPA 10 1998 4-3.1.

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the area of the cited deficiencies because smoke and fire could pass between building stories.

Findings include:

A. At 2:45 PM on October 29, 2013, the following deficiencies were observed at the ventilation shaft accessed from inside the Third Floor Psychiatric Unit Staff Lounge:

1. A duct penetration through the west wall of 2 hour fire rated ventilation shaft was observed which lack a fire damper required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1.

2. Pipe or other penetrations in the west wall of the ventilation shaft were observed which are not sealed against the passage of fire as required by 8.2.3.2.4.2.

Based on random observation during the survey walk-through, staff interview, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the immediate area because fire could be permitted to pass between building stories.

Findings include:

A. On the afternoon of October 29, 2013, 6th Floor ventilation shaft corridor wall adjacent to SW Stair was observed with ducts and installed fire dampers. The ducts are not installed with retaining angles in accordance with a tested design for fire dampers.

B. On the morning of October 30, 2013, Third Floor, designated two hour fire rated wall between the Mechanical Room and the Engineering Office vestibule was observed with duct penetration that is not fire dampered.

C. On the morning of October 30, 2013, Third Floor, the designated two hour fire separation wall near the Director of Facilities office was observed with a non self-closing and a non rated door which is required to be 1 1/2 fire rated.

D. On the afternoon of October 30, 2013, Second Floor O.R. Based upon observation and based upon staff interview, the surveyor finds that the fire damper installed for the duct located above the ceiling of the Decontamination Room was not maintained and tested since 08/19/03.

A. ased on direct observation the afternoon of 10/30/13 while in the company of Chief Engineer, the surveyor finds the facility failed to maintain the manual means for activating the kitchen hood fire suppression system. The manual pull station was hanging loose from the ceiling and not supported from a stable surface.

B Based on direct observation the afternoon of 10/30/13 while in the company of Chief Engineer, the surveyor finds the facility failed to provide a "Class K" portable fire extinguisher for the cafeteria cooking area.

6th Floor:
By direct observation the morning of 10/30/13 while in the company of Chief Engineer, the surveyor finds the linen chute door is not maintained to be self closing. This will allow products of combustion (i.e. fire and smoke) to escape to the interior of the building and not be contained to the chute itself.


16339


Based on observation the Linen Chute was not provided by fire resistive construction with a fire door assembly. This deficiency could affect any patients, staff, or visitors in the area because fire and smoke could pass through an improperly rated chute door.

Findings include:

A. On the morning of October 31, 2013 First Floor, the surveyor observed the door label to the Linen Chute Room discharge was painted.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

A. At 1:46 PM on October 30, 2013, carts and equipment were observed, in the basement Corridor immediately west of Exit Stair C (and immediately north of the door to the Kitchen) which obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1.

Based on random observation during the walk-through, the surveyor observed that exit access corridors were obstructed and are not maintained in accordance with 7.1.10 and 19.3.6.1. Failure to maintain the means of egress will delay movement or evacuation in an emergency.

Findings include:

A. On the afternoon of October 30, 2013 Second Floor Cath Lab Area. The aisle was obstructed by medical carts.

Based on random observation during the survey walk-through, not all medical gas piping systems are installed and maintained in accordance with NFPA 99. These deficiencies could affect any patients in the cited area becasue the medical gas system could become compromised.

A. At 9:23 AM on October 30, 2013, the manual medical gas zone (shut-off) valves serving the northeast set of Second Floor Same Day Surgery Prep/Recovery Bays were observed to be located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d).

Based on direct observation the morning of 10/30/13 while in the company of Chief Engineer, the surveyor finds the facility failed to maintain the medical air compressor intake per NFPA 99, 1999, 4-3.1.1.9. (b). The screen cover for the intake needs repair and cleaning. These deficiencies allow for possible contamination of the breathable medical air system and putting patients at risk needing respiratory assistance.


16339


Based on direct observation, the surveyor finds the facility failed to provide separation by an intervening wall between the medical gas zone valves and the outlets they serve to comply with NFPA 99, 1999, 4-3.1.2.3 (d). These deficiencies could pose a potential hazard to patients if medical gas zone valves are not installed properly in accordance with NFPA 99.

A. On the afternoon of October 30, 2013, by direct observation the surveyor finds that not all medical gas zone valves are separated from the outlets/inlets they serve. This does not comply with NFPA 99, 1999, 4-3.1.2.3. Locations observed:

1. First Floor, Cath Lab Suite in the Patient Holding area.

Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the generator installation did not meet all of the requirements of NFPA-110. This could affect all occupants of the building if the generator does not operate during the loss of normal power.

Findings include:

A. The generator was not equipped with a remote manual stop station in accordance with NFPA-110, Section 3-5.5.6.

B. The facility's remote annunciator was not located at a location that was staffed 24/7 as required by NFPA-99, Section 3-4.1.1.15.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.


17659


Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the elevator installation did not meet all of the requirements of ANSI/ASME A17.3. This could affect all occupants of the building if the elevators do not operate properly during an emergency.

Findings include:

B. The elevator equipment room was equipped with sprinklers, but there was not a heat detector located within 2' of each sprinkler head, and there was no means to automatically disconnect the main power supply to the elevator prior to application of water in the machine room or shaft as required by ASME 17.1, Section 102.2.c.3.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. Panels LP-LL, and Panel ESS2 in the main electrical room had mixed loads that were not separated into the proper emergency branches as required by NFPA-70, Section 517-32 through 517-34.

Based on random observation with the O.R. Manager and the Maintenance Technician present the surveyor finds that electrical installations and materials do not comply with NFPA 70-1999:

Findings include:

A. On the morning of October 30, 2013, Second Floor O.R., Electrical Panels located on the corridor near the Sterile Storage Room were observed to being blocked with medical carts and the required 3'-0" clearance is not being maintained in front of the panels.


17659


Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect any patient undergoing surgery if the transfer switch serving the operating rooms fails.

Findings include:

B. The operating rooms were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

Based on random observation during the survey walk through while accompanied by the Director of Engineering, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect any occupant of the building using the elevator during a power outage.

Findings include:

A. The cab lighting for the hydraulic elevator was fed from a normal power panel 3NPB, rather than a life safety panel as required by NFPA-70, Section 517-32.

B. The electric panel in the kitchen near the hood ansul system was missing a directory as required by NFPA-70, Section 110-22. Several panel directories throughout the facility needed updating.

Based on staff interview, interim life safety and other required measures are not implemented when the building fire alarm system is out of service for more than 4 hours in a 24 hour period as required by 9.6.1.8. These deficiencies could affect any patients, staff, or visitors in the building

Findings include:

A. During a test of the building fire alarm system conducted on the morning of October 31, 2013, it was determined that portions of the system had been disabled by contractor forces. During an interview held at 11:45 AM on that date, the provider's Director of Facilities confirmed that the following steps required by 9.6.1.8. had not occurred as a result of the fire alarm system shutdown:

1. No fire watch was implemented while the portions of the fire alarm system was disabled.

2. The Authority Having Jurisdiction was not advised of the partial fire alarm system shutdown.