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Based on observations and staff interviews, it was determined that the facility failed to meet the minimum construction requirements based on construction type limitations. This deficient practice could affect patients, staff and visitors if a fire in the deficient area were to compromise the building's structural integrity during a fire emergency.

Findings include:

On January 9, 2018 at 1:30 PM, while accompanied by the DPS and CE, Stairwell on the 7th Floor, the surveyor observed structural beams which are missing fire proofing. This does not comply with Table 19.1.6.1 and NFPA 220 2012 Ed. Table 4.1.1 for a protected fire resistant assembly.

Based on observation during the survey walk-through, not all egress paths are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress could be impeded under emergency conditions if they are not maintained.

Findings include:

A. On January 9, 2018, while accompanied by the CPM, observation determined that means of egress are not maintained continuously free of obstructions as required by 7.1.10.2.1. Locations observed include:

1. At 1:25 PM while accompanied with the facility representatives, 7th Floor North Exit corridor alcove was being used as storage for gurneys, chairs and other combustible material separated from exit corridor with privacy curtain.
2. At 2:05 PM while accompanied with the facility representatives, 4th Floor North Exit corridor alcove was being used as storage for gurneys, chairs and other combustible material separated from exit corridor with privacy curtain.

Based on observation during the survey walk-through, not all egress paths are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress could be impeded under emergency conditions if they are not maintained.

Findings include:

A. On January 9, 2018, while accompanied by the VPO, observation determined that means of egress are not maintained continuously free of obstructions as required by 7.1.10.2.1. Locations and obstructing pieces of equipment observed include:

1. 2:10 PM, 5th Floor, computer on wheels across from North Exit Stair.

2. 2:35 PM, 4th Floor, 2 computers on wheels in East Corridor.

B. On January 9, 2018, while accompanied by the VPO, observation determined that chairs serving Satellite Nurse Stations obstruct egress, in a manner prohibited by 7.1.10.2.1, because the chairs protrude into the Corridor. Locations of Satellite Nurse Stations observed include:

1. 2:20 PM, 5th Floor, 2 Satellite Nurses' Stations in East Corridor.

2. 2:40 PM, 4th Floor, 2 Satellite Nurses' Stations in East Corridor and 1 in South Corridor.

Based on observation, means of egress are not continuously maintained free of impediments to full use. Occupants ability to promptly reach an area of safety could be compromised if an unobstructed means of egress is not provided during an emergency.

Findings include:

On January 10, 2018 at 10:55 AM while accompanied by the DPS, the surveyor observed that the 5th floor, Dialysis Unit, has one of the two required exit paths passing through an intervening Storage Room (containing cardboard boxes, in a quantity deemed hazardous) This arrangement of egress to an exit does not comply with 39.3.2.1 and 7.5.1.6.

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

Findings include:

On January 10, 2018 at 1:42 PM, while accompanied by the VPO, observation determined that the 3rd Floor Temporary Nurses' Station lacks a side-hinged, swinging door, as required by 7.2.1.4.1.

Based on observation during the survey walk-through, not all stairways are constructed as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if stairways are not properly constructed.

Findings include:

On January 10, 2018, while accompanied by the VPO, observation determined that exit stair enclosures lack directional signage, within the exit stair enclosure and at each landing, as required by 7.2.2.5.4.1(A). Locations observed include:

A. 2:35 PM: North Exit Stair.

B. 2:38 PM: South Exit Stair.

Based on observation during the survey walk-through, not all stair components used within an exit stair are constructed to provide a safe enclosure. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions if the exit stairs are not constructed properly.

Findings include:

On January 10, 2018 at 11:00 AM, while accompanied by the DPS, Exit Stair # 3 on the 1stt Floor, was observed to contain a non-rated usable space under the Stair which contained a stored chair and floor tile materials. This does not comply with 7.2.2.5.3 and 7.2.2.5.3.1.

Based on observation during the survey walk-through, not all building stories or fire compartments are provided with at least two remote exits. This deficient practice could affect patients, staff, and visitors in the building because they could be prevented from exiting the building under emergency conditions if an insufficient number of exits is provided.

Findings include:

While accompanied by the VPO, observation determined that building stories exist at which at least two exits are accessible from every part of the building, as required by 19.2.4.3, because cross-corridor doors are secured against passage toward the South Exit Stair. Locations observed include:

A. January 10, 2018, at 2:37 PM: 5th Floor from the area served by the North Exit Stair toward the south.

B. January 11, 2018, at 8:50 AM: 1st Floor from the area served by the North Exit Stair toward the south.

Based on observation during the survey walk-through, not all dead end corridors are limited in length as required. This deficient practice could affect patients, staff, and visitors using the corridors because they could be prevented from exiting the building under emergency conditions if dead end corridors ore of excessive length.

Findings include:

On January 9, 2018, while accompanied by the VPO, observation determined that dead end corridors exceed 30 feet in length as prohibited by 19.2.5.2. Locations observed include:

A. 2:15 PM: 5th Floor South Corridor, from south end of corridor to intersection of corridors at Nurses' Station.

B. 2:25 PM: 4th Floor South Corridor, from south end of corridor to intersection of corridors at Nurses' Station.

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

Findings include:

On January 10, 2018 at 2:05 PM, while accompanied by the VPO, observation determined that the 2nd Floor West Elevator Lobby lacks direct access to a corridor, required by 19.2.6.5.1, because the sole door out of the room is secured against passage.

Based on observation during the survey walk-through, not all patient care sleeping suites are configured as required. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the patient care sleeping suites are not configured in a complaint manner.

Findings include:

On January 9, 2018 at 1:45 PM, while accompanied by the VPO, observation determined that the 6th Floor West ICU Suite lacks access access to a corridor, as required by 19.2.5.7.2.1(A), because the space provided at the North Exit Stair is not a complaint corridor as it lack two remote exits required by 19.2.5.4.

Based on observation during the survey walk-through, not all egress paths are complete to a public way. This deficient practice could affect any patients, visitors, and staff in the building because their ability to reach may be impeded if a complete egress path is provided.

Findings include:

On January 11, 2018 at 10:15 AM, while accompanied by the VPO, observation determined that the exterior egress path at the South Exit Stair is not complete to a public way, as required by 7.7.1, because the path includes a section of grass.

Based on observation during the survey walk-through, not all egress paths are visible as required. This deficient practice could affect patients, staff, and visitors because egress could be impeded under emergency conditions if they are not maintained.

Finding includes:

On January 9, 2018, at 2:25PM while accompanied with CPM, directional exit sign was not readily visible on 2nd floor egress corridor by Nuclear Medicine, as required by with Sections 19.2.10.1 and 7.10.

Based on observation during the survey walk-through, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

On January 10, 2018 at 2:39 PM, while accompanied by the VPO, observation determined that the sign which directs occupants toward the 5th Floor landing of the South Exit Stair reads "STAIR" and not "EXIT" as required by 7.10.3.1.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all occupants within the areas of the facility, by preventing them from readily identifying the path to an available exit from the building in case of an emergency.

Findings include:

Exit signs are not provided which identify the 2nd means of egress from corridors to the adjacent compartments. This does not comply with 19.2.10.1 and 7.10. Locations observed:

A. On January 10, 2018 at 10:15 AM while accompanied by the DPS only one path of exit
access was observed to be identified by exit signage at the 2nd Floor, OR Unit.

B. On January 10, 2018 at 10:35 AM, while accompanied by the DPS, the surveyor observed that the 2nd Floor at the North end / West end corridors adjacent to the Endoscopy Suite were observed to lack means to identify both egress paths.

C. On January 10, 2018 at 10:35 AM, while accompanied by the DPS, the North end / West end corridors adjacent to the Endoscopy Suite were observed to lack means to identify both egress paths.

D. On January 10, 2018 at 10:40 AM, while accompanied by the DPS, the surveyor observed that the 2nd Floor aisles to the Pre/ Post Operating Recovery Suite lack means to identify paths to the nearest exit.

E. On January 10, 2018 at 10:45 AM, while accompanied by the DPS, the surveyor observed on the 2nd Floor Atrium that the path of egress travel leading to designated exits is not obvious due to lack of exit signs.

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

Findings include:

A. While accompanied by the CPM, observation determined that the vertical pipe penetration through floor were not fire sealed around to maintain the fire rating of the construction type in accordance with Sections 19.3.1.1 to 19.3.1.6. Locations includes but not limited to the following:

1. January 9, 2018 at 8:45 AM: Basement electrical room, 3 pipes

2. January 10, 2018 at 9:30 AM: .Basement compressor/mechanical room, 3 pipes

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

Findings include:

A. On January 11, 2018, while accompanied by the VPO, observation determined that door assemblies exist in exit enclosures, other than those permitted by 7.1.3.2.1(9) as prohibited by 7.1.3.2.1(10)(a). Locations observed include:

1. 9:48 AM: 2nd Floor South Exit Stair landing, door to Storage Room.

2. 9:58 AM: 1st Floor South Exit Stair landing, door to Storage Room.

B. On January 11, 2018, while accompanied by the VPO, observation determined that ductwork penetrates exit enclosure walls as prohibited by 7.1.3.2.1(10)(d). Locations observed include:

1. 1st Floor South Exit Stair landing:
a. 9:56 AM: Duct through north enclosure wall serving diffuser within Exit Stair.

b. 10:02 AM: Two grilles through east enclosure wall (from Storage Area located under stair) into the interstitial space above the ceiling in the Exit Stair.

C. On January 11, 2018, at 10:00 AM, while accompanied by the VPO, observation determined that a Storage room exists, within the enclosure for the South Exit Stair and beneath the treads and risers, which is not separated from the Exit Stair enclosure by minimum 1 hour fire rated construction as required by 7.2.2.5.3.2.

Based on observation during the survey walk-through, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Finding includes:

On January 11, 2018 at 2:05 PM while accompanied with CPM, it was observed that five pipes penetrating the floor above had voids around them and were not sealed with fire proofing in the fire pump room, per requirements of Section 8.7.1.

Based on observation during the survey walk-through, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building.

Findings include:

A. On January 9, 2018 at 2:25 PM while accompanied with CPM, fire dampers penetrating the two-hour fire wall in the mechanical room on 3rd floor, was observed to have opening between the damper sleeve and the wall, not installed as per Manufacturer's Installation Instruction. Sections 19.5.2, 9.2.1 and 2010 Edition of NFPA 80 - Section 19.2.1.6.

B. On January 10, 2018, while accompanied with CPM, pipes penetrating the hazardous room walls were not sealed for fire/smoke resistance, in accordance with Section 8.7.1. Locations observed:

1. At 8:45 AM Electrical room in the basement is not protected with an automatic sprinkler system and contains two - 4" pipes and one- 12" openings which penetrate the north wall.

2. At 8:50 AM in the Electrical room in the basement is not protected with automatic sprinkler system and had a pipe penetrating the one-hour wall that was filled with rock wool.

3. At 8:55 AM 40' tunnel storage had nine pipes penetrating the south wall behind the electric junction box.

4. At 9:30AM Compressor/Mechanical Room had 6 pipes penetrating the wall which were not sealed for smoke/fire resistance.

C. On January 10, 2018 at 10:05 AM, while accompanied by the VPO, observation determined that the door to the 1st Floor Kitchen Dry Storage Room not self-closing as required by 19.3.2.1.3, Table 8.3.4.2, and NFPA 80 2010 6.4.1.1.

D. On January 10, 2018 at 10:35 AM, while accompanied by the VPO, observation determined that 1 leaf of a pair of doors serving the 1st Floor Storage Room M175 does not carry a minimum 3/4 hour fire resistance rating, as required by 19.3.2.1 and Table 8.3.4.2, because the fire rating label is not present.

Based on observation during the survey walk-through, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Findings include:

A. On January 10, 2018 at 10:05 AM, while accompanied by the VPO, observation determined that the door to the 1st Floor Kitchen Dry Storage Room not self-closing as required by 19.3.2.1.3, Table 8.3.4.2, and NFPA 80 2010 6.4.1.1.

B. On January 10, 2018 at 10:35 AM, while accompanied by the VPO, observation determined that 1 leaf of a pair of doors serving the 1st Floor Storage Room M175 does not carry a minimum 3/4 hour fire resistance rating, as required by 19.3.2.1 and Table 8.3.4.2, because the fire rating label is not present.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's exit access corridors if the corridors are not properly separated.

Findings include:

A. On January 10, 2018 at 9:00 AM while accompanied by the DPS, the surveyor observed that the 2nd floor, OR Unit, Operating Room #9 is being used for miscellaneous combustible storage. The doors do not comply with 19.3.2.1.3 for self-closing doors.

B. On January 10, 2018 at 10:20 AM while accompanied by the DPS it was observed, on the 2nd floor, OR Unit, an Alcove was observed open to the means of egress corridor. The Alcove contained storage of medical devices, medical supplies and plastic combustible materials. The space is 72 square feet and is not separated from the exit access corridor. This does not comply with 19.3.2.

C. On January 10, 2018 at 10:30 AM while accompanied by the DPS it was observed, on the 2nd Floor of the Cath Lab, Recovery Suite that one of the recovery bays is being used as a storage (containing stretcher beds, carts, supplies and nurse carts, deemed hazardous). This does not comply with 19.3.2.1 for hazardous areas.

Based on observation during the survey walk-through, the facility failed to provide compliant interior room finishes. This deficient practice could affect patients, staff, and visitors in the hospital because the non-compliant finishes could contribute to a fire if they are not fire retardant-treated.

Findings include:

On January 9, 2018 at 2:41 PM, while accompanied by the VPO, observation determined that the plywood finish in the 4th Floor North Supply Room is not a Class A or Class B finish, as required by 19.3.3.2, because no label is visible which demonstrates that the product is fire retardant-treated.

Based on an observation, the facility failed to properly install all required initiating devices to provide a functioning fire alarm system. This deficient practice could affect patients, staff and visitors if smoke was not detected and the fire alarm system did not operate due to the placement of a smoke detector.

Findings include:

A. On January 10, 2018 , while accompanied by DPS, the surveyor observed several smoke detectors that were located less than 3-feet from a mechanical supply vent which does not comply with 9.6, and NFPA 72 2010 Edition, Section 17.7.6.3.2. Locations observed:

1. At 9:00 AM, 2nd Floor designated horizontal exit between the Main and the Galter connecting bridge leading to the OR Unit.

2. At 9:15 AM, 2nd Floor Soiled Utility Room for the OR Unit and Recovery Unit located near the Electrical Closet.

B. On January 10, 2018 at 3:00 PM while accompanied by DPS and CE it was observed that a smoke detector was not provided from the 3rd Floor, at the LDR Unit smoke barrier corridor door ( adjacent to the Mechanical Room ). This does not comply with NFPA 72-2010, 17.7.5.6.

Based on observation during the survey walk-through, the fire alarm system is not secured from tampering. This deficient practice could affect all occupants of the building if the fire alarm has been tampered with and fails to initiate.

Finding includes:

On January 10, 2018 at 8:55 AM while accompanied with the CPM, it was observed that thefire alarm circuit breakers in the electrical room panel were not mechanically secured from tampering, in accordance with 2010 Edition of NFPA 72, 10.5.5.3.

Based on observation during the survey walk-through, smoke detectors are not installed properly. This deficient practice could affect patients, staff, and visitors in the building if the smoke detectors failed to initiate alarm in case of a fire event.

Findings include:

A. On January 10, 2018 at 9:10 AM while accompanied with the CPM, it was observed the smoke detectors were installed at less than 3'-0" from HVAC diffusers as prohibited by NFPA 72 201017.7.4.1. Locations observed:

1. Call center office.

2. Emergency room office.

B. On January 10, 2018 at 9:10 AM while accompanied with the CPM, it was observed the smoke detectors were not installed in the basement in a non-sprinkler building in accordance with 19.3.6. Locations observed:

1. SODEXO office.

2. Call center manager office.

3. Coding manager office.

4. Registration office.

5. Storage closet.

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

The finding are:

A. On January 10, 2018 at 8:50 AM in the company of the CE, the surveyor finds there is a lack of sprinkler protection for the interstitial return air plenum for the bridges connecting the Parking Deck, Galter Medical Pavilion and Main Building. A continuous ceiling return air opening the length of the bridges allows for heat and products of combustion to enter the interstitial space bypassing the ceiling sprinkler installation. NFPA 13, 2010, 8.1.1


B. On January 10, 2018 at 9:00 AM in the company of the CE, the surveyor finds the lack of sprinkler protection for building elevator machine room except for those hydraulically operated. This building is considered to be fully sprinkler protected. NFPA 13, 2010, 8.1.1

Based on observation during survey walk-through, the sprinkler system is not maintained. This deficient practice could affect patients, staff, and visitors in the building if the sprinkler system failed to activate in the event of a fire emergency.

Finding includes:

On January 11, 2018, at 12:45 PM while accompanied by the CPM, observation determined that the concealed sprinkler system in EVS (janitor) Room # F147 had the cover plate missing, and not in accordance with 2011 Edition of NFPA 25, 5.2.1.1.2(5).

Based on observation during survey walk-through, the sprinkler system is not maintained. This deficient practice could affect patients, staff, and visitors in the building if the sprinkler system failed to activate.

Finding includes:

On January 11, 2018, at 2:05 PM while accompanied by the CPM, observation determined that the two-pendent sprinkler heads in the Sleep Lab control room had lint on them, which will prevent the activation of the sprinkler system in a timely manner, and not in accordance with 2011 Edition of NFPA 25, 5.2.1.1.2(5).

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.

Findings include:

On January 9, 2018 at 2:40 PM, while accompanied by the DPS and CE, the surveyor observed, on the 3rd Floor, LDR Unit, an Alcove with a desk chart which is open to the adjacent corridor. This area is not arranged to provide the 24/7 direct observation from the nurse station and lacks a smoke detector. This does not comply with the 19.3.6.1.1 c).

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

Findings include:

On January 10, 2018 at 2:20 PM, while accompanied by the VPO, observation determined that the 2nd Floor Quiet Room door is not positive latching as required by 19.3.6.5(1).

Based on observation during the survey walk-through not all doors in exit access corridors are in compliance. This deficiency could affect all patients in the locations as well as any staff, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied if the corridor doors are not properly installed and maintained.

Findings include:

On January 10, 2018 at 9:00 AM while accompanied by the DPS, the surveyor observed the 2nd floor, OR Unit, Operating Room #9 was not provided with a means of keeping the door closed to comply with 19.3.6.5.

Based on observation during the survey walk-through, the facility failed to install and maintain Phase I and Phase II fireman's recall on all elevators as required. This deficient practice could affect any patients, staff, and visitors in the hospital because smoke and fire could be permitted to spread throughout the building via the elevator shafts, and the elevators could be unavailable to firefighters when needed, if the recall systems are not properly installed.

Findings include:

On January 10, 2018 at 2:31 PM, while accompanied by the VPO, observation determined that the Elevator serving the Winona Building is not equipped with Phase I elevator recall and Phase II firefighters' emergency operations as required by 9.4.3.2.

Based on observation during the survey walk through the facility failed to correctly install components for the elevator firefighter service and recall systems. Failure to install and maintain these systems could result in malfunction and response of the recall function. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On January 10, 2018 at 10:45 AM accompanied by the CE, it was observed in the elevator machine room for Elevator #5 that heat detectors are not installed within 2 feet of the sprinkler head for elevator shutdown. NFPA 101, 2012, 19.5.3 / ANSI A17.1, 2007, 2.8.3.3.2 & NFPA 72, 2010, 21.4.2.

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

Findings include:

On January 10, 2018 at 9:04 AM, while accompanied by the VPO, observation determined that 3rd Floor Electrical Panel CRPP-NW3-1, which is not a designated portion of the Life Safety Branch of the hospital's Type 1 Essential Electrical System (EES), serves a Fire Alarm Control Panel which is required to be served by the Life Safety Branch for compliance with NFPA 99 2012 6.4.2.2.3.2(7) and NFPA 70 2011 517-32(C)(1).

Based on observations, the facility failed to provide proper electrical identifications in electrical areas. This deficient practice could affect patients, staff and visitors if electrical circuits are not properly labeled.

Findings include:

On January 10, 2018 at 9:00 AM, while accompanied by the DPS, it was determined that on the 2nd Floor, OR Unit, Electrical Room, identified electrical panels GPP-AM2-4, GPP-AMP-3 and CRDP- AM2-2 have panel directories that are not updated. This does not comply with the requirements of NFPA 70, 2011 edition, Section 408.4.

Based on observation, not all electrical receptacles are installed as required. This deficient practice could affect any patients, staff, and visitors in the building because electrical power may not be available for use when required.

Findings include:

On January 10, 2018 at 2:00 PM, while accompanied by the VPO, observation determined that all 3rd Floor Patient Sleeping Rooms lack at least 1 duplex electrical receptacle, which is served by the hospital's emergency power system, as required by NFPA 70 2011 517-18(A).