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Based on observation, the facility failed to provide the proper arrangement of means of egress. This deficient practice could affect patients, staff and visitors if occupants could not safely egress from a fire emergency.

Findings include:

On July 27, 2022, at 1:10pm, while in the company of the FM, it was observed on the Lower Level that a long corridor comes to a dead end leading to the southwest corner of the purchasing department. All doors within the corridor are locked and not otherwise in compliance with the allowable locking arrangments covered in 19.2.2.2.4. Therefore, a dead-end corridor far exceeding 30 feet in length exists. This condition does not comply with Section 19.2.5.2.

Based upon observation, signage is not placed appropriately to identify available exit paths, or distinguish doors which appear to be exits but are not. Failure to correctly identify exit paths can result in occupants not being able to identify and reach available exit paths during a fire/smoke emergency.

A. On July 27, 2022, it was observed that illuminated exit signage is not provided as required by Section 19.2.10.1 and 7.10. to identify the means of egress:

1. At 10:15am in the Mother/Baby unit on the 3rd floor, while in the company of the CM, it was observed that "Exit" signage with direction to the path of egress that is visible at the intersection of the north/south corridor and the east/west corridor.


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2. At 2:15 pm at the 1st floor Stair 7 north wall, while in the company of the DOF, it was observed that "Exit" signage with direction to the path of egress that is visible to the people coming down from upstairs was not provided.

3. At 1:15 pm, at the 1st floor Cafeteria main circulation hallway, while in the company of the DOF, it was observed that the path of egress is blocked by a half wall and "Exit" signage with direction to the path of egress was not provided.

B. On July 27, 2022, while in the company of the DOF, it was observed that signage is not provided as required by Section 19.2.10.1 and 7.10.8.3. to identify doors which can be mistaken for a means of egress:

1. At 11:05 am at the 2nd floor Chiller Room west side doors leading to the roof, it was observed that "NO EXIT" signage was not provided.

2. At 1:29 pm at the 1st floor hallway door leading to the enclosed courtyard, it was observed that "NO EXIT" signage was not provided.

Based upon observation, signage is not placed appropriately to identify available exit paths. Failure to correctly identify exit paths can result in occupants not being able to identify and reach available exit paths during a fire/smoke emergency.

The findings are:

On 7/27/22, at 2:30pm while accompanied by the DPO, it was observed that illuminated exit signage is not provided in the second-floor northeast corridor and third-floor north corridor as required by Section 39.2.10 and 7.10. to identify the means of egress.

Based upon observation, signage is not placed appropriately to identify available exit paths. Failure to correctly identify exit paths can result in occupants not being able to identify and reach available exit paths during a fire/smoke emergency.

The finding is:

On July 28, 2022, at 10:05am it was observed that an illuminated exit sign is installed at the east end of the hallway in the EEG suite, as labeled on the provided Life Safety Plans. The door was observed to be locked This condition does not comply with Section 19.2.10.1 and 7.10.

Based on observation, the HVAC Ducts penetrating rated walls are installed with fire dampers not in compliance with the manufacturers' installation instructions. Failure to properly install protective devices can compromise the safety of occupants during a fire emergency.

Findings include:

On July 27, 2022, while in the company of the CM, it was determined that the fire dampers installed in Mechanical Room W 348 walls were found not installed per manufacturers' installation instructions. The detail is in question because intumescent fire caulk is installed too close to operable components. Improper installation is not in compliance with Section 8.3.3.2.

Based on observation, hazardous areas are not separated from the general occupancy of the building. Failure to properly separate hazardous areas from the general occupancy of the building will affect the safety of all patients, staff, and visitors if a fire were to occur. This deficient practice is not in compliance with Section 39.3.2, & 8.7.

The finding is:

On 7/27/22, at 2:30pm while accompanied by the DPO, it was observed that the unfinished space on the third floor is being utilized for storage of combustible material. Furthermore, through wall ducts, pipe and conduits were observed not sealed for smoke and fire resistance.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate hazardous areas from required means of egress paths can compromise the safety of occupants during a fire emergency.

The findings are:

On July 28, 2022, at 9:54am, while in the company of the FM, it was observed on the Lower-Level within an area designated as a suite on the provided Life Safety plans, that the space labeled Therapists (4) was used for storage of combustible materials. The space was observed not sprinkler protected and there was no self-closing/self-latching hardware on the door serving the space. It was also observed that the other spaces within the suite, such as Infant Hearing Program, was not sprinkler protected. Therefore, neither the suite nor the space Therapists(4) are in compliance with 19.3.2.1.

Based upon observation and staff interview, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate hazardous areas from required means of egress paths can compromise the safety of occupants during a fire emergency.

On July 27, 2022, the following deficiencies were observed:

A. At 11:15am, while in the company of the FM, it was observed that the Lower-Level corridor between the spaces labeled Meeting Room 079 and Electrical Switch Gear Room on the provided Life Safety plans are used for the storage of combustible materials and are not separated from the means of egress by construction capable of resisting the passage of smoke to comply with Section 19.3.2.1.2 and 8.4

B. At 1:05pm, while in the company of the FM, it was observed that the Lower-Level corridor between the spaces labeled Clean Linen and Infection Control on the provided Life Safety plans are used for the storage of combustible materials and are not separated from the means of egress by construction capable of resisting the passage of smoke to comply with Section 19.3.2.1.2 and 8.4.


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C. At 10:45 am, while in the company of the DOF, it was observed that the 2nd floor OR area hallways are used for the storage of combustible materials and are not separated from the means of egress by construction capable of resisting the passage of smoke to comply with Section 19.3.2.1.2 and 8.4

D. At 10:13 am, while in the company of the DOF, it was observed that the 2nd floor CCU Medication Storage Room is not separated from the means of egress by construction capable of resisting the passage of smoke, including a self-closing door assembly, to comply with Section 19.3.2.1.2 and 8.4

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

On July 27, 2022, the following deficiencies were observed:

A. At 9:53am, while in the company of FM, it was observed on the 7th floor at the West end of the corridor between the spaces labeled Media Services 743 and Production Room 746 on the provided Life Safety plans, there is a large gap in the ceiling. No complete and continuous physical separation from the room to the ceiling cavity above exists. The missing ceiling material would allow heat and products of combustion to bypass the installed smoke detector and therefore does not comply with NFPA 72-2012, 17.7.3.2.4.2.


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B. At 9:51am, while in the company of the DOF, a Smoke Detector was observed installed near an HVAC register at the 2nd floor OR Recovery area hallway is not in compliance with NFPA 72-2010, Section 17.7.4.1.

C. At 1:10pm, while in the company of the DOF, a Smoke Detector was observed installed near an HVAC register at the 1st floor Kitchen area is not in compliance with NFPA 72-2010, Section 17.7.4.1.

Based on observation during the building tour 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 July 27, 2022, at 11:25am, while in the company of the FM, it was observed on the Lower-Level that two sprinkler heads were missing escutcheon rings in the space labeled Processed Stores on the provided Life Safety plans. This installation does not comply with NFPA 13-2010, 6.2.7.2.

B. On July 27, 2022, at 1:21pm, while in the company of the FM, it was observed on the Lower-Level that a sprinkler head was missing an escutcheon ring in the space labeled Dietetic Suite on the provided Life Safety plans. This installation does not comply with NFPA 13-2010, 6.2.7.2.

C. On July 27, 2022, at 1:29pm, while in the company of the FM, it was observed on the Lower Level, that there is no sprinkler protection provided in in the space labeled Storage 042 on the provided Life Safety plans. The installation is not in compliance with NFPA 13-2010, 8.1.1(1).

Based on observation, the facility failed to conduct required maintenance and testing necessary to maintain the sprinkler system. This deficient practice could affect patients, staff and visitors, if a sprinkler system failed to function as designed due to the lack of required maintenance and testing.

Findings include:

A. On July 26, 2022, at 2:30pm, while in the company of the DPO, FM and CM, the documentation for the Five-Year Fire Department Connection/Hydrostatic Piping test as required by NFPA 25-2011, Table 5.1.1.2, was not available for review. Prior to the surveyors' departure, the facility provided correspondence from a vendor confirming the inspection and testing would begin August 1, 2022.

B. On July 27, 2022, at 11:20am, while in the company of the FM, it was observed on the Lower Level, that the facility had failed to maintain the sprinkler heads free of foreign materials. Sprinkler heads in the housekeeping suite were covered in an excessive amount of lint and foreign debris. This condition does not comply with NFPA 25-2011, 5.2.1.1.1.

Based on observation, the facility failed to conduct required maintenance and testing necessary to maintain the sprinkler system. This deficient practice could affect patients, staff and visitors, if a sprinkler system failed to function as designed due to the lack of required maintenance and testing.

Findings include:

On July 28, 2022, at 10:00am, while in the company of the FM, it was observed on the Lower Level, that the facility had failed to maintain the sprinkler heads free of foreign materials. Typical sprinkler heads on the Lower-Level were observed covered in an excessive amount of lint and foreign debris. This condition does not comply with NFPA 25-2011, 5.2.1.1.1.

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

Findings include:

On July 28, 2022 at 10:00am while accompanied by the FM, the elevator machine room was observed in use as a place for storage of combustible materials not directly related to the function of the space, and therefore does not comply with Section 9.4.2.2, ANSI/ASME A17.3 2008 edition, section 2.2.1.

Based on observation and staff interview during the building tour the facility lacks complete protection 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.

Findings include:

On July 27, 2022, at 2:46 pm while in the company of the FM, it could not be confirmed through direct observation that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with NFPA 70-2011 Edition, Section 250.104 (B).

Based upon observation, electrical systems are not maintained in accordance with Code requirements. Failure to maintain electrical systems can result in shock hazard to occupants upon contact with electrical components.

Findings include:

A. On July 27, 2022, at 11:00am, while in the company of the FM, it was observed on the Lower-Level in the Emergency Generator Room that a junction box with wiring connections lacked closure of the box with a cover plate to comply with NFPA 70-2011, 314.28(C).

B. On July 27, 2022, at 11:16am, while in the company of the FM, it was observed on the Lower-Level in the space labeled Pump Room 062 on the provided Life Safety plans that a junction box with wiring connections lacked closure of the box with a cover plate to comply with NFPA 70-2011, 314.28(C).

C. On July 27, 2022, at 1:30pm, while in the company of the FM, it was observed on the Lower-Level in the mechanical room between the spaces labeled Oxygen Storage and 042 on the provided Life Safety plans that a junction box with wiring connections lacked closure of the box with a cover plate to comply with NFPA 70-2011, 314.28(C).

D. On July 27, 2022, at 1:42pm, while in the company of the FM, it was observed on the Lower-Level in the space labeled 025 on the provided Life Safety plans that a junction box with wiring connections lacked closure of the box with a cover plate to comply with NFPA 70-2011, 314.28(C).

E. On July 27, 2022, at 1:49pm, while in the company of the FM, it was observed on the Lower-Level in the space labeled Equipment Room 002 on the provided Life Safety plans that a junction box with wiring connections lacked closure of the box with a cover plate to comply with NFPA 70-2011, 314.28(C).

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

On July 27, 2022, the following deficiencies were observed:

A. At 10:19am, while in the company of the FM, it was observed on the 6th floor that an electrical receptacle in the space labeled Nourish 628 on the provided Life Safety plans is within 6'-0" of a sink and is not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(5).

B. At 10:25am, while in the company of the FM, it was observed on the 6th floor that two electrical receptacles in the space labeled Soiled Utility 644 on the provided Life Safety plans are within 6'-0" of a sink and are not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(5).

C. At 10:25am, while in the company of the FM, it was observed on the 6th floor that two electrical receptacles in the space labeled Soiled Utility 644 on the provided Life Safety plans are within 6'-0" of a sink and are not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(5).


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D. At 11:25 am, it was observed that electrical receptacles at the 1st floor and 2nd floor hallways serve drinking fountain and are not provided with GFCI protection in accordance with NFPA 70-2011, 422.52.

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

The finding is:

On July 27, 2022 at 2:05pm, while in the company of the FM, it was observed that typical exam room receptacles are within 6'-0" of a sink and not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(5).

Based on observation, the diesel powered Emergency Generator is located within the Building and not protected as required. This deficiency will affect affect all patients, staff and visitors if the facility were to experience a fire.

The findings include:

A. On 7/27/22 at 2:30pm while accompanied by the DPO, it was observed that the generator is installed in the building and a 2 hour fire rated enclosure in compliance with NFPA 110-2010, Section 7.2.1.1. could not be verified.

B. On 7/27/22 at 2:30pm while accompanied by the DPO, there was no emergency stop switch observed outside the room housing the prime mover in compliance with NFPA 110-2010, Section 5.6.5.6.