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Based on observation and staff interview the means of egress is not maintained in accordance with Code requirements. Failure to maintain means of egress in all areas can result in delayed or unsafe evacuation during an emergency event.

Findings include:

A. On 04/25/2023 at 9:00am while in the company of the SO, it was observed from penthouse windows that rooftop equipment is served by walkways constructed with pavers. The pavers are placed adjacent to the buildings' parapets which are not otherwise provided with required guards. This condition does not comply with 19.2.1, 7.1.8, and 7.2.2.4.


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B. On 04/24/2023 at 1:20 pm while in the company of the FM, it was observed that the exit door was installed with incorrect direction and exit hardware at the Ground Floor Electrical Room # TG142. This does not comply with 2012 Edition of NFPA 101, Section 19.2.2.2 and 7.2.1.4.2.

Egress doors are locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

The finding is:

On 4/24/2023 at 1:30pm while accompanied by the SO on the first floor it was observed that locking devices are not installed in accordance with 19.2.2.2.4. Exit doors from the unit were observed to be equipped with Delayed Egress magnetic locking devices which do not comply with 19.2.2.2.4(2) and 7.2.1.6.1.1(4) because the required signage was not installed.

Based on observation, not all stairs or fire/smokeproof enclosures are constructed and maintained as required including stair components within the stair enclosure. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained.

The findings include:

A. On 04/24/2023 at 11:45am while accompanied by the ADF Stair # 3 level of discharge, storage room under the stair landing is not determined to be separated from the stair by a U.L. listed design for a 2-hour fire rated separation. Location - 1st floor storage room adjacent to room # 1139 Organizational Development.

B. On 04/25/2023 at approximately 11:50 am while accompanied by the ADF it was observed that there are exit stairs ( #6 and #9) serving numerous floor levels. It is noted that these stairs discharge to the interior of the building. The life safety floor plan indicates that these stairs discharge to 2-hour fire rated enclosures (exit passageways). The current condition of these passageways do not comply with 7.1.3.2.1(10), 7.1.3.2.2, 7.2.6.3. All contain piping, ductwork conduits etc which do not serve these corridors. Further these corridors contain suspended acoustical tile lay in ceiling which does not comply with 7.1.3.2.2 for a protected fire rated enclosure.

Based on observation and staff interview, illumination of exit discharge portion of the means of egress is not provided to maintain continuous illumination. Failure to maintain illumination of the means of egress can prevent safe and unimpeded access to the public way in the event of an emergency evacuation for all building occupants.

Findings include:

A. On 04/24/2023 at 3:00 pm while in the company of the FM, in general, it was observed that the exit discharge lights were installed with a single lamp fixture. This does not comply with 2012 Edition of NFPA 101, Section 19.2.7, 7.7 and 7.8.1.4.

Locations observed:
1. Ground Floor Corridor # TG216 exit discharge area.
2. Ground Floor Corridor # TG007 exit discharge area.

Based upon observation and staff interview, exit signs are 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.

Findings include:

A. On 04/24/2023 at 2:10 pm while in the company of the ADF, exit signage was observed which is not fully visible due to building signage. This condition does not comply with 2012 Edition of NFPA 101, Section 19.2.10.1 and 7.10.1.8 Location observed second floor corridor adjacent to Risk Management Office.


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B. On 04/24/2023 at 1:00 pm while in the company of the FM, in general, it was observed that the exit signage was not provided to identify the means of egress throughout the Ground Floor to comply with 2012 Edition of NFPA 101, Section 19.2.10.1 and 7.10.
Locations observed:
1. Several Ground Floor Patient Care suits.
2. Several Ground Floor Non-Patient Care suits.
3. Several Ground Floor MEP suits.
4. Several Ground Floor hallways and tunnels

C. On 04/24/2023 at 3:00 pm while in the company of the FM, in general, it was observed that the exit signage provided throughout the Ground Floor corridors and tunnels is not fully visible at all locations due to pipes in the ceiling and inadequate illumination. This condition does not comply with 2012 Edition of NFPA 101, Section 19.2.10.1 and 7.10.1.8.

D. On 04/24/2023 at 1:20 pm while in the company of the ADF, it was observed that the exit signage was not provided to identify the means of egress to comply with 2012 Edition of NFPA 101, Section 19.2.10.1 and 7.10 Location observed: Corridor adjacent to Ambulatory Surgery Registration lacks exit signage leading to a remote exit in both directions.

Based on 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 if a fire were to originate at the stored material to block exiting.

Findings include:

On 4/25/2023 at 9:27am while in the company of the SO it was observed that the door serving Mechanical Room T6001 did not self-close to a smoke tight condition. Therefore, this installation is not in compliance with 19.3.2.1.2.

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

The finding is:

On 04/25/2023 while in the company of the ADF, manual pull stations are not located within 5 feet of the designated exit door to comply with 19.3.4.2.1, NFPA 72, 2010, 17.14.6.

Example locations observed:

1. At 1:50 pm 1st floor entry to 2-hour designated exit passageway #T1039 for Stair #4 and Stair # 3 separation at the pair of cross corridor doors corridor #T1046 entry to passageway and Hall #T1032 to passageway.

2. At 2:02 pm1st floor corridor adjacent to Health Information Management leading to Stair #6 passageway lacks a manual pull station.

3. At 2:08 pm 1st floor corridors adjacent to Lab and Xray leading to Stair #11 passageway lacks a manual pull stations.

4. At 2:20 pm 1st floor corridor #T1134 leading to Stair #9 passageway lacks a manual pull station.

Based on observation the facility failed to install 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.

The findings are:

A. On the following dates and times accompanied by the ADF, the surveyor finds:

1. 04/24/23 at 12:30 pm, 2nd Floor Equipment Closet located in scope storage room part of GI suite S-2C
is not provided with fire sprinklers. NFPA 13, 2010, 8.1.

3. 04/24/23 at 2:00 pm in the Ambulatory Surgery waiting room, the fire sprinkler coverage is obstructed by a ceiling soffit. and vending machine NFPA 13, 2010, 8.6.5

4. 04/24/23 at 1:25pm in Stair #12, fire sprinkler protection is not provided under the first accessible landing above the bottom of the stair shaft. NFPA 13, 2010, 8.15.3.2.1




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B. On 4/24/2023 at 1:20pm while accompanied by the SO on the first floor it was observed that a concealed sprinkler head was missing a cap in the Emergency Department Vestibule. This installation does not comply with NFPA 13-2010, 6.2.7.2.


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C. On 04/24/2023 at 1:40 pm, while in the company of FM, it was observed that the facility did not maintain 18-inch clearance from the bottom of sprinkler heads to obstructions. This does not comply with 2010 Edition of NFPA 13, Section 8.5.6.1.

Locations observed:
1. Ground Floor Store Room # TG133.
2. Ground Floor Medical Records Filing Room # G104.


D. On 04/24/2023 at 2:30 pm, while in the company of FM, it was observed that the acoustic ceiling tiles were open. Open ceiling tiles allow heat and/or smoke to enter the interstitial space above and delay or prevent the operation of the suppression system. This does not comply with 2010 Edition of NFPA 13, Section 8.6.4.1.1.

Locations observed:
1. Ground Floor Store Room # TG214.
2. Ground Floor Pre Registration, Insurance and Financial Verification Room # G107E.

Based on observation, not all corridor doors are installed and maintained to remain in the closed position. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass into corridors if the corridor doors are not installed in a compliant manner.

Findings include:

A. On 04/24/2023 at 2:00 pm, while in the company of FM, in general, it was observed that several corridor doors at the Ground Floor were propped open. This does not comply with 2012 Edition of NFPA 101, Section 19.3.6.3.5.

Based on observation, soiled linen chutes and rubbish chutes are not protected. Failure to protect these areas during a fire/smoke event, permits fire/smoke to migrate from one room or area to other floor levels rather than being contained.

The finding is:

On 04/24/23 while accompanied by the ADF limted access gravity chutes with intake doors open to the corridor are not secured to comply with NFPA 82, 2009 5.2.1.2, 5.2.3.3.2.4. These are not considered general access chutes ( an apartment building) and therefore 5.2.1 does not apply.
This was observed in the following locations outside of semi restricted and restricted areas (staff only) to include:
1. 2:10 pm First floor Hallway T1138 ( patient care non sleeping suite leads to exit passageway Stair #11)
2. 1:45 pm First floor Corridor T1127 adjacent to Stair #9 (verify all floor levels)

Based upon review of record documentation of door inspections, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. Failure to maintain doors can compromise adjacent spaces during a fire condition.

Finding includes:

A. On 04/25/23 while in the company of the ADF, documentation for fire rated doors was reviewed. The following information was not available:
There is no indication a complete fire door inspection was conducted for 2022 to comply with any requirement of 7.2.1.15. For example:

1. There is no indication that all doors requiring repair or modification have recieved them to comply with 7.2.1.15.8, NFPA 80 2010, 5.1.5.1 for an immediate resolution. There are currently 82 doors remaining to correct without an indication of being completed.

2. There is no indication that any door has been inspected from both sides of the door to comply with 7.2.1.15.6.


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B. On 04/24/2023 at 2:30 pm, while in the company of FM, it was observed that the corridor door is broken and does not latch to a closed position at Ground Floor Laundry Room # G634A. This does not comply with 19.3.6.3.5.

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.

The finding is:

On 4/25/2023 at 1:00pm while accompanied by the SO it could not be confirmed that electrical bonding of the building's medical gas piping system has been completed. This is not in compliance with NFPA 70-2011, 250.104 (B).

Based on observation the facility failed to install a compliant Category 1 Medical Gas System. This deficient practice could result in the failure / response during a fire event, which may affect patients, staff and visitors.

A. On 04/25/23 at 9:00 am, in the company of the ADF, it was observed that zone valves are installed within the same space for the outlets/inlets they control and not placed on a interveneing wall at the following locations, NFPA 99, 2012, 5.1.4.8. Location observed: Second Floor PACU

B. On 04/25/23 at 9:12 am in the company of the ADF it was observed that zone valves are labeled to indicate the shutting off of gases to both O.R. #1 and PACU. Both the vacuum shut off valve and the medical air shut off valve list both "O.R. #1" and "Recovery" on their labels. The sign adjacent to the shut off reads "Zone Valve Box 2 - REC 1 serves rooms 2-202 and OR 1 South wall". This condition does not comply with NFPA 99, 2012, 5.1.4.8.7.2

C. On 04/25/23 at 9:12 am in the company of the ADF it was observed that zone valves do not have readily observable labels to indicate the type of gases it serves. Location observed 2nd floor corridor Zone Valve box 2.4. This condition does not comply with NFPA 99, 2012, 5.1.11.2.1.

D. On 04/25/23 at 9:12 am in the company of the ADF it was observed that zone valves are labeled to indicate the shutting off of gases to both O.R. #1 and PACU. The hallway outside of O.R. #1 and PACU contains a shut off valve for oxygen. the adjacent sign reads "Zone Valve Box 2 - REC 1 serves rooms 2-202 and OR 1 South wall". The valve located within PACU contains a shut off for oxygen which also reads the same as the shut off in the corridor. Therefore it appears there are two valves providing the same purpose and both do not comply with NFPA 99, 2012, 5.1.4.8.7.2



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E. On 04/24/2023 at 1:18pm while in the company of the SO it was observed that zone valves are installed within the same space for the outlets/inlets they control at the following locations, NFPA 99-2012, 5.1.4.8. Location observed: Nuclear Med suite

Based on observation, portions of the medical gas piping systems are improperly supported. Failure to support the piped system properly could result in misuse or disruption of medical gas services. This deficient practice could affect patients and staff if services were unexpectantly disrupted.

The finding is:

On 4/24/2023 at 1:40pm while in the company of the SO on the first floor above the ceiling at CT-2 it was observed that medical gas system piping is supported entirely on ductwork within the ceiling space. This installation does not comply with NFPA 99-2012, 5.1.10.11.4.

Based on observation, portions of the facility lack identification of the medical gas piping systems. Failure to label this installation could result in misuse or disruption of medical gas services. This deficient practice could affect patients and staff if services were unexpectantly disrupted.

The finding is:

On 4/24/2023 at 1:40pm while in the company of the SO on the first floor above the ceiling at CT-2 it was observed that medical gas system piping is not labeled in accordance with NFPA 99-2012, 5.3.11.1.1.

Based on observation, not all electrical receptacles are installed as required. this deficient practice could affect patients, staff, and visitors in the building because electrical power may not be available for use when required if they are not installed properly.
Findings include:

A. On 04/24/23 at 1:10 pm while accompanied by the ADF, observation determined that electrical receptacles, served by the emergency power system, are not labeled as to electrical panel and circuit as required by NFPA 70 2011 517-19(A).
Location observed: Second floor PACU


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B. On 04/24/2023 at 1:33 pm while in the company of the FM, it was observed that electrical receptacle at the Ground Floor S-GB suite Kitchen, Room #G224 is within 6'-0" of sink and is not provided with GFCI protection to comply with 2011 Edition of NFPA 70, Section 210.8(B)(5).

Based on observation the generator room lacks the required enclosure. Failure to properly separate hazardous areas from other occupied areas can compromise the safety of occupants if a fire were to originate in the generator.

Findings include:

On 4/25/2023 at 9:27am while in the company of the SO it was observed that the 2 pairs of double doors serving the generator room did not self-close and self-latch due to missing and malfunctioning hardware. Therefore, this installation is not in compliance with NFPA 99-2012, 6.4.1.1.8.1A and NFPA 110-2010, 7.2.1.1.