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Based on observations and interviews, the facility failed to provide proper lighting within the exit stairways. This deficient practice could affect patients, staff and visitors when trying to exit the building during an emergency.

The finding is:

On 1/11/2022 at 2:14 PM while accompanied by SM and SE it was identified that on the 4th floor, exit stair 4ASTR1 the light fixture was not functioning at the landing. This does not comply with NFPA 101, 7.2.2.

Based on observation, means of egress doors are locked using noncompliant methods. Failure to install locking devices for means of egress doors in full compliance with all requirements can result in building occupants not being able to reach an area of safety or an exit during a fire/smoke event.

Findings include:

On 01/11/2022 at 2:50pm while accompanied by the SC, on the First floor between both Emergency Departments, a pair of cross corridor doors in East/West corridors #1R56 and #1R52 do not comply with the following:

1. The doors contain delayed egress which does not comply with 7.2.1.6.1 (3)(d) relocking requirements of a manual reset.

2. The doors are not inidcated to be part of a smoke barrier, therefore 19.3.7.8 (2) for non latching hardware does not apply. These doors do not comply with 19.3.6.3.5 and 19.3.6.3.7 for the latch edge requirements on a swinging door.

Based on observation vertical enclosures are not protected from other parts of the building. This deficient practice compromises the use of a stair as an exit and could affect all visitors, staff and patients when evacuating a floor or building during a fire smoke event.

A. On 01/12/2022 at 1:15pm accompanied by the SC, Exit Stair #Pstr 56 which serves 1st through 5th floor and roof contains windows (full height of the stair) located approximately 7'-4" from the adjacent nonrated exterior building wall. The adjacent non rated exterior building wall also contains windows adjacent to the exterior wall of the stair. The angle of exposure is less than 180 degrees therefore protection of either the stair or the adjacent wall is to comply with 7.2.2.5.2.1 and 7.2.2.5.2.2 for a minimum 10'-0".

Location observed: second floor of Exit stair #Pstr -56 and second floor HR office

B. On 01/12/2022 at 9:20am accompanied by the SC Exit Stair #1Mstr3 enclosure serves 14 floors and contains an exit door which contains the following:

1. A damaged fire rated label which does not comply with 8.3.3.2.3 and NFPA 80 2010, 3.2.4, 4.2.1
2. The door appears to read that it is a C label (3/4 hour rating) which does not comply with 19.2.2.3, 7.1.3.2.1(3) and table 8.3.4.2 Location observed: 1st floor exit stair #1 Mstr 3

Based on observations and interviews, the facility failed to provide exit stairways enclosed with construction having the proper fire resistance rating to provide a continuous path of escape from exit discharge to public access way. This deficient practice could affect patients, staff and visitors if fire and smoke were to enter the exit enclosure and encumber evacuation of the facility during a fire emergency.

The finding is:

On 1/11/2022 at 1:58 PM while accompanied by SM and SE it was identified that on the 4th floor, door to exit stair 4BSTR2 did not latch to the door frame when tested. This does not comply with NFPA 101, 8.15.5.

Based on observation not all exit enclosures are separated from surrounding areas by a fire resistance rating that is required for the stair(s) it serves. This deficient practice could affect all patients in the facility, as well as any staff and visitors present, by not providing a sufficent number of exits from the building.

The finding is:

On 01/12/2022 at 9:40am while accompanied by the SC exit passageway's were observed which do not maintain the fire rated construction of the stair(s) they serve to comply with 19.2.2.5, 7.2.6.3 and 7.1.3.2.1 and 8.3.5.
Example conditions and location observed:
1st floor C building exit passageway for Stair #1Mstr 3 contains doors which are 3/4 hour fire rated doors which does not comply with 19.2.2.2, 7.1.3.2.1(3) (a), (b) or (c). This exit passageway serves a 14 story exit stair in a partially sprinklered healthcare building.

Based upon observation, rooms or suites contain means of egress which are not remotely located. Failure to provide compliant egress routes can compromise the safe means of egress for any visitors, staff and patients.

Findings include:

On 01/12/2022 at 11:50am while in the company of the SC, a partially sprinklered non patient care suite/room was observed which lacked remote exiting to a means of egress corridor to comply with 19.2.5.5.2. Both designated exits are located on the West side of the room.
Location observed: 1st floor Kitchen

Based upon observation, suites are to be separated from adjacent areas and other suites to provide for compliant egress during a fire smoke emergency. Failure to provide compliant separation can compromise the means of egress for any visitors, staff and patients.

The finding is:

On 01/12/2022 at 10:50am while in the company of the SC, the suite separation wall of a non patient care suite does not comply with 19.2.5.7.1.2 (1). The wall separating the kitchen from dishwashing contains a means of egress door which does not comply with 19.3.6.3 for corridor door requirements.

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:

A. On 01/11/22 while accompanied by the FM, observation determined that directional exit signs are not provided to direct the occupants to the nearest exit to comply with 7.10.3.1.
Example locations:

1. At 2:10pm 11J66

2. At 2:20pm 10th floor by room 10J66 and 10H6


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B. On 01/12/2022 accompanied by the SC corridors and suites were observed to lack exit signs to clearly identify access to at least two remote means of egress from the locations to comply with 19.2.4.3, 19.2.10 and 7.10.
Example locations:

1. At 10:20am 1st floor exit stair #1Pstr56 exiting from stair is at intermediate landing not viewable from the path of egress upon entering the stair from the corridor.

2. At 10:55am 1st floor exiting from the Kitchen through the dishwashing area lacked a designated exit sign.

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.

Findings Include:

A. On 1/11/2022 at 2:10 PM while accompanied by SM and SE it was identified on the 4th floor, south exit corridor, southeast end of the corridor lacked an exit sign to comply with 7.8.1.2 and 19.2.8.

B. On 1/11/2022 at 2:20 PM while accompanied by SM and SE it was identified on the 3rd floor, southeast corner, clinic space. West end of exit corridor does not have an Exit sign adjacent to 3B318 inside the corridor. This does not comply with 7.8.1.2 and 19.2.8.


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C. On 1/12/2022 at 12:43pm, while in the company of the EMF it was observed in the basement floor mechanical room that plumbing components obstruct the illuminated exit sign. Obstruction of required exit signage is not permitted under 39.2.10, 7.10.1.8.

Based upon observation, exits are not marked in accordance with Code requirements. If exits are not marked as required, then occupants may not be able to safely egress in the event of an emergency. This deficient practice could affect the safety of building occupants.

The finding is:

On 1/11/2022 at 1:35pm, while in the company of the FA it was observed in the 5th floor Stress Lab that only one illuminated exit sign is installed. Under 39.2.4 a single means of egress is not permitted from this space.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire emergency.

Findings include:

A. On 01/12/2022 at 11:01am while in the company of the SC, the kitchen storage room located in the dishwashing area, does not comply with 19.3.2.1.2 and 19.3.2.1.3 due to the following:

1. Door does not self close.
2. Door does not latch.

B. On 01/12/2022 at 1:56pm while in the company of the SC, a storage room door to the Storage #2A450, Surgery Department, does not comply with 19.3.2.1.2 and 19.3.2.1.3 due to the following:

1. Door does not self close.
2. Door does not latch.

Based on observations not all enclosures of hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building due to smoke and fire passing from the hazardous area through the remainder of the building.

Findings include:

A. On 1/11/2022 at 1:40 PM while accompanied by SM and SE it was identified that on the 6th floor, room 6B214 is being used for storage. The door was not provided with a closing device to protect the exit corridor. This does not comply with NFPA 101, 39.3.2.

B. On 1/11/2022 at 1:48 PM while accompanied by SM and SE it was identified that on the 5th floor electrical room 5B108 contains a sprinkler pipe passing through the 1-hour enclosure that did not contain fire proofing in the annular space around the pipe. This does not comply with NFPA 101, 39.3.2.

C. On 1/11/2022 at 2:24 PM while accompanied by SM and SE it was identified that on the 3rd floor electrical room 3A160 contains a 2-inch hole in the 1-hour barrier that was not fire-stopped. This does not comply with NFPA 101, 39.3.2.

D. On 1/11/2022 at 2:30 PM while accompanied by SM and SE it was identified that on the 3rd floor, Environmental Closet 3A101, door to the exit corridor did not latch to the frame when tested. This does not comply with NFPA 101, 39.3.2.

E. On 1/11/2022 at 2:40 PM while accompanied by SM and SE it was identified that on the 2nd floor, Soiled Cart Storage 3T612, door to the exit corridor did not latch to the frame when tested. This does not comply with NFPA 101, 39.3.2.

Base on observation the facility failed to maintain the 1st Floor kitchen hood suppression system. Failure of this system during a grease fire may affect the safety of patients, staff and visitors.

The findings are:

A. On 1/12/22 at 11:15 am in the company of SC, the K Portable Fire Extinguisher was visually obstructed by a large garbage container in non-compliance with NFPA 10, 6.1.3 & 6.1.3.3.

B. On 1/12/22 at 11:15 am in the company of SC, the blowoff caps for the hood fire suppression system were not installed for the protection of the discharge nozzles. NFPA 17 &17A, 2009, 4.3.1.5


Based on document review and staff interview record of inspection and cleaning activity is not documented for the kitchen grease hood and duct system. Failure to inspect and clean this system may affect the safety of patients, staff and visitors.

The finding is:

C. On 1/13/22 at 10:30am in the company of FM, written documentation of the inspection and cleaning activities for the kitchen grease hood and duct system could not be provided. Only a purchase order was presented for this activity. NFPA 96, 2011, 11.5

Based on observation smoke detectors throughout the hospital are not located as required for a compliant fire alarm system installation. Failure to locate devices accordingly may result in failure or delay of alarm initiation device during an emergency event. If alarm initiating devices do not function properly, then the building occupants may not be alerted to an emergency which may result in occupants' safety being compromised.

The finding is:

It was observed at various locations that detectors are located where airflow may prevent normal operation of the device as written in NFPA 72-2012 17.7.4.1. Locations & conditions observed include the following:

1. On 1/12/2022 at 9:32am, while in the company of the FA, it was observed that a smoke detector was within 3"-0" of an HVAC diffuser on the 6th floor in room 6W10.

2. On 1/12/2022 at 9:52am, while in the company of the FA, it was observed that a smoke detector was within 3"-0" of an HVAC diffuser on the 4th floor in room 4W106.

3. On 1/12/2022 at 10:10am, while in the company of the FA, it was observed that a smoke detector was within 3"-0" of an HVAC diffuser on the 4th floor in room 4W119.

4. On 1/12/2022 at 11:04am, while in the company of the FA, it was observed that a smoke detector was within 3"-0" of an HVAC diffuser on the 1st floor in room 1W9.

Based on observation smoke detectors throughout the hospital are not located as required for a compliant fire alarm system installation. Failure to locate devices accordingly may result in failure or delay of alarm initiation device during an emergency event. If alarm initiating devices do not function properly, then the building occupants may not be alerted to an emergency which may result in occupants' safety being compromised.

The finding is:

It was observed at various locations that detectors are located where airflow may prevent normal operation of the device as written in NFPA 72-2012 17.7.4.1. Locations & conditions observed include the following:

1. On 1/11/2022 at 1:33pm, while in the company of the FA, it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in the 5th floor corridor near room 5P95.

2. On 1/11/2022 at 1:38pm, while in the company of the FA, it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in room 5P62 on the 5th floor.

Based on observation, the fire pull stations are not properly located. This could affect patients, staff and visitors of the areas served if the fire alarm system does not operate properly during a fire emergency.

The finding is:

While in the company ofof the SC, manual pull stations are not located within 5 feet of the designated exit door to comply with 19.3.4.2.1, 9.6.2.3.(2), NFPA 72, 2010, 17.14.5 and 17.14.6.

Locations observed:

1. On 01/11/2022 at 2:40pm 1st floor 2-hour desiginated fire compartment separation at the pair of cross corridor doors between compartment F and E corridor leading into Interventional Radiology Dept. from compartment F.

2. On 01/12/2022 at 8:50am 1st floor 2-hour designated fire compartment separation at the pair of cross corridor doors between compartments J and T in the direction of exiting towards T.

3. On 01/12/2022 at 10:11am 1st floor exit passageway for stair #1Kstr11 at cross corridor exit passageway entry from compartment F, and adjacent corridors in compartment K and Radiology.

4. On 01/12/2022 at 10:17am 1st floor exit passageway which serves both #1Mstr 3 and #1Mstr 7 at cross corridor exit passageway entry from compartment J and compartment C.

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 01/12/22 at 2:20pm while accompanied with FM, the alcove in the means of egress was observed to have wooden shelves stored with combustible paper books and plastic toys. The type of shelves, locations and amount provide an obstruction to sprinkler protection not in compliance with Section 38.3.2.1 and NFPA 13, 2010, 8.5.5.3.

Based on observation the facility failed to install complete fire protection sprinkler coverage. Failure to install and maintain a complete fire protection system may affect patients, staff and visitors during a fire event.

Findings include:

A. On 1/12/22 at 12:35pm in the company of the FM in the Basement, the Morgue's refrigerated body cooler is not provided with fire sprinkler protection to comply with NFPA 13, 2010, 8.1.1 for a fully sprinklered building.


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B. On 1/12/2022 at 11:02am, while in the company of the FA, it was observed on the first floor in room 1W22 that ceiling tile was missing which would allow heat and products of combustion to bypass the installed sprinkler heads. This is not in compliance with NFPA 13-2010, 8.6.4.1.

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. On 1/11/22 at 1:20pm in the company of the FM, in the stair tower at the 12th floor (12HSTR1) abandoned sprinkler heads have not been removed to comply with NFPA 13, 2010, 26.2. By staff interview this condition exists on all 12th floor stair landings.

B. On 1/12/22 at 1:15pm in the company of the FM, in the 1st Floor Receiving (1M5) Loading Dock, sprinklers are installed such that open overhead doors obstruct sprinkler protection. This condition does not comply with NFPA 13, 2010, 8.4.2 (3), 8.5.5.3.1.


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C. On 1/12/2022 accompanied by the SC, missing ceiling tile were observed. This condition can delay activation of a sprinkler head by allowing heat and combustive materials to by pass the sprinkler. This condition does not comply with NFPA 13-2010, 8.6.4.1. Example locations observed:

1. At 11:02am located above the freezer in the kitchen

2. At 10:37 located in laundry chute room #1F070A

Based on observation the facility failed to maintain access to the fire pump room. Failure to maintain access to the exterior for responding personnel during a fire event may affect patients, staff and visitors.

The finding is:

A. On 1/12/22 at 10:20am in the company of the FM, the require protected access to the 1st floor fire pump room (1A207) contained stored items i.e. trash cans and carts, wood pallets, floor maintenance equipment. This condition does not comply with NFPA 20, 2010, 4.12.2.1.1.


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Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

B. On 1/11/2022 at 1:15 PM while accompanied by SM and SE it was identified that the elevator machine room was not sprinkler protected. The sprinkler piping was installed but cut off from the water source. No sprinkler heads were installed only caps at the head locations were present. This does not comply with NFPA 13, 8.1.

Based on observation not all exit access corridors are separated from use areas. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke to enter the egress corridor.

The finding is:

On 01/11/2022 at 2:10pm while accompanied by the SC the surveyor observed perimeter walls of a nonsprinklered corridor which do not comply with 19.3.6.2.1. as a barrier to limit the transfer of smoke. Location observed:
The corridor located East of the Lab (compartment D1), the west wall (fire rated) contains numerous holes, gaps in the blocks and block cores which are not sealed.

Based upon observation, corridor doors are not positive latching. Failure to provide positive latching corridor doors can compromise the effectiveness of the door to remain closed to prevent the passage of smoke from one side of the corridor wall to the other.

The finding is:

On 01/12/2022 at 10:20am while in the company of the SC, it was observed that corridor doors were equipped with a thumb turn lockset on the egress side. This does not comply with 19.3.6.3.5 for a corridor door which is required to have a means for keeping the door in the closed position (latched not locked). Closing and latching the door requires several operations rather than one motion which does not comply with 7.2.1.4.1 (4) (c), 7.2.1.5.10.2. Location observed: 1st floor K building, room across the corridor from Storage #1233.

Base on observation the facility failed to separate the kitchen grease duct from environmental ventilation ducts within the fire rated enclosing shaft. This deficient practice could result in the uncontrolled spread of fire and products of combustion during a kitchen hood/duct fire event, which may affect patients, staff and visitors.

The finding is:

On 1/11/22 at 1:35pm in the company of the FM, at the 12th floor mechanical room (12000), the duct enclosure (shaft) for the 1st floor kitchen hood grease duct contains environmental supply air ventilation ducts which does not comply with NFPA 90A, 2012, 5.3.4.5.

Based on document review and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

Finding includes:

On 01/13/2022 at 9:30am during document review with the SC, Facility fire drills for the past 12 months did not indicate that all notifications and participants are included. The Facility's Fire Safety Plan is to comply with 19.7.1. and 4.7.2. Not all requirements are documented as follows:

1. documented compliance with 19.7.1.4 for the indication that the alarm has been transmitted and recieved by the monitoring service.

2. documented compliance with 19.7.1.6 as indication of the activated device and audible alarm.

3. documented compliance with 19.7.1.6 and 4.7.2 for the indication that all employees subject to the drill participate (this includes individuals located in adjacent compartments, and/or floors).

Based on staff interview the facility lacks complete bonding of the medical gas piping system. Failure to install and maintain this installation could result in the piping system to become electrically energized. This deficient practice could affect patients and staff.

The finding is:

On 1/11/22 at 2:45pm in the company of the FM, it could not be confirmed through observation and staff interview that electrical bonding of the facility's medical gas piping systems has been completed. This is not in compliance with NFPA 70, 2011, 250.104 (B)

Based on staff interview the facility lacks complete bonding of the medical gas piping system. Failure to install and maintain this installation could result in the piping system to become electrically energized. This deficient practice could affect patients, staff and visitors.

The finding is:

On 1/11/22 at 2:15pm in the company of the FM, it could not be confirmed through observation and staff interview that electrical bonding of the facility's medical gas piping systems has been completed. This is not in compliance with NFPA 70, 2011, 250.104 (B)

Based upon observation and staff interview, not all patient bed locations are provided with electrical power in accordance with Code requirements. Failure to provide electrical power at patient bed locations can disrupt use of bedside equipment used by patients.

Findings include:

On 1/12/2022 at 2:40pm, while in the company of the FA it was observed that the C-Section Procedure Rooms where not served by both normal power and emergency power to comply with NFPA 70-2011, 517-19(A); no normal power receptacles were observed. Furthermore, it could not be determined by observation or staff interview that these rooms were otherwise served by two separate transfer switches in accordance with NFPA 70-2011, 517-19(A), exception No. 2.

Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

Findings include:

On 1/12/2022 at 10:10am, while in the company of the FA it was observed in the 4th floor Family Lounge that 2 electrical receptacles are within 6'-0" of a sink fixture and are not provided with GFCI protection to comply with NFPA 70-2011, 210.8(B)(5).