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Based on observation, means of egress doors are not maintained free of impediments to access areas of refuge or exits from the building. Failure to provide an unobstructed means of egress can compromise occupants' ability to promptly reach an area of safety.

Findings include:

A. On 6/28/17 at 10:55am while in the company of the DFS & RNS it was observed that the 2nd floor OR #7 corridor door was equipped with both a latching device and a dead bolt lock which could require two releasing operations to open the door when both are engaged which does not comply with 7.2.1.5.10.2.

B. On 6/28/17 at 1:5pm while in the company of the DFS it was observed that the Mezzanine level MRI Control room horizontal sliding corridor door was equipped with both a non-functional latching device (see K 0363) and a dead bolt lock which could require two releasing operations to open the door when both are engaged which does not comply with 7.2.1.5.10.2.

Based upon observation, exit stair enclosures are not maintained to meet their required fire resistance rating. Failure to maintain the fire resistance rated enclosure of the exits can compromise the level of safety the exit is expected to provide for building occupants.

Findings include:

On 6/28/17 at 9:35am it was observed while, in the company of the DFS, that the 2nd floor Stair D door (within the Lab) was not self-latching to comply with 7.1.3.2.1, 8.3.3.1 and 8.3.3.2.

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the normal power supply. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On 6/28/17 at 2:35pm while in the company of the DFS, it was observed that the exit discharge lighting at the Mezzanine level south exit door to the loading dock/exterior stair area was not of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 7.9.1.3.

Based upon observation, Exit signage is not provided to accurately identify access to Exits. Failure to accurately identify exit paths can confuse occupants and delay occupants from accessing the safety of an exit.

Findings include:

A. On 6/28/17 at 9:35am while in the company of the DFS & RNS, it was observed on the 2nd floor in the corridor(s) leading to the Respiratory Therapy/Pulmonary Function/Lab areas that exit signs were not provided to the east to identify the access to the 2nd means of egress to comply with 19.2.5.4 and 7.10.1.5.

B. On 6/28/17 at 1:10pm while in the company of the DFS, it was observed on the Mezzanine level that the corridor north of Stair E lacks exit signage at the west end cross corridor doors to comply with 19.2.5.4 and 7.10.1.5.

C. On 6/28/17 at 1:15pm while in the company of the DFS, it was observed on the Mezzanine level within the West Emergency Dept. suite that directional exit signage was not provided at the east end of the south corridor to comply with 19.2.5.4 and 7.10.1.5.

D. On 6/28/17 at 1:30pm while in the company of the DFS, it was observed on the Mezzanine level within the West Emergency Dept. suite that exit signage was not provided at the east corridor to identify access to the north exterior exit door to comply with 19.2.5.4 and 7.10.1.5.

E. On 6/28/17 at 2:25pm while in the company of the DFS, it was observed on the Mezzanine level in the east-west corridor serving the Dishwashing room that exit signage at the west end of the corridor was turned 90° so as not to be visible from the east portion of this corridor to comply with 19.2.5.4 and 7.10.1.5.

Based on observation the facility failed to connect the grease duct system fans to duct with bolted connections. This deficient practice could result in the uncontrolled spread of fire and products of combustion during a kitchen hood fire event, which may affect patients, staff and visitors.

Findings include:

On 6/27/17 at 1:15PM in the company of MM while touring the 5th floor roof top mechanical penthouse, the surveyor observed the connections between the kitchen grease ducts and the exhaust fans were made using flexible connectors as prohibited by NFPA 96, 2011, 8.1.3.4 & 5.

Based on observation, the facility failed to provide visual alarms throughout the facility. This deficient practice can affect patients, staff and visitors if the failure to install a complete system hinders notification to occupants.

Findings include:

On 6/27/17 at 9:05 AM, while in the company of MM, and touring the 5th floor "closed" med surg unit, it was noted that Room 565E was being utilized as an "on-call room". The room was observed to not contain visual alarms (strobes) as required by NFPA 72, 18.5.4.6.

Based on observation, sprinklers are not installed and maintained in all spaces to comply as a fully sprinklered building. Failure to install and maintain the sprinklered building could compromise the suppression of a fire affecting all occupants of the building in case of fire event.

Findings include:

On 6/28/17 between 1:40pm and 1:50pm while in the company of the DFS, it was observed that ceiling tile was missing or out-of-place to permit the ceiling to be open to the cavity above. The above ceiling cavity is not sprinklered. This condition does not comply with NFPA 13-2011, 8.6.4.1.

Location observed include:

A. In the Mezzanine level MRI Equipment room.
B. In the Mezzanine level southwestern Corridors near the Shell space storage rooms.


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Based on observation during the survey walk through the facility failed to install sprinkler protection in correct orientation to the overhead ceiling obstructions. 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:

On 6/28/17 at 9:45AM in the company of MM while touring the Ground Level general store room (0087), the surveyor observed that the fire sprinkler heads are installed more than 6 inches below the obstructing joists of the pan/joist building structural construction. This is not in compliance with NFPA 13, 2010, 8.6.4.1.2.

Based on observation, not all spaces open to corridors are protected to comply with Code provisions. Failure to provide protective measures can result in delayed notification of a fire/smoke event which can compromise the use of the corridors or the response to the fire/smoke condition.

Findings include:

On 6/28/17 at 10:35am it was observed while in the company of the DFS & RNS that the 2nd floor same-day surgery waiting area ceiling spaces near the public toilet rooms lacked smoke detection to comply with 19.3.6.1(1)c.

Based upon observation, corridor doors are not constructed to be resistant to the passage of smoke by providing positive latching hardware. Failure to provide corridor doors which resist the passage of smoke can compromise the use of the corridor as a means of egress or provide safety within a room as an area of refuge for any occupants during a fire/smoke event originating on the other side of the corridor wall and affect all occupants.

Findings include:

A. On 6/28/17 at 1:05pm while in the company of the DFS, it was observed on the Mezzanine level that two Dining room north corridor doors were not provided with latching hardware to comply with 19.3.6.3.1 because the panic hardware provided was dogged in the open position.

B. On 6/28/17 at 1:50pm while in the company of the DFS, it was observed that the Mezzanine level MRI Control room horizontal sliding corridor door did not have hardware to keep the doors closed and latched to comply with 19.3.6.3.5 and 19.2.2.2.10. This door was also equipped with a separate dead latch (see K 0211).

Based on observation during the survey walk-through, not all portions of the building piped medical gas system are installed in accordance with Code requirements. Failure to install medical gas systems in accordance with requirements can result in failure of the system to perform without hazard to the occupants.

Findings include:

On 6/28/17 at 1:10pm while in the company of the DFS, it was observed that an oxygen outlet was controlled by a zone valve located adjacent to the outlet which is not in compliance with NFPA 99-2012, 5.1.4.8(1) & (3).