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Based on observation, 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 properly installed and maintained.

Findings include:

A. On 08/29/2022 at 1:30pm while in the company of the DFM it was observed that delayed egress locks are installed which lack the required signage indicating a 15 second delay for release of the lock. This condition does not comply with 7.2.1.6.1.1.(4).
Example location:
1. Third floor Stair #7 (West end of Fairfield Wing)

B. On 08/29/2022 while in the company of the DFM, it was observed that the delayed egress locking devices installed at egress doors lack the means for manual reset to comply with 7.2.1.6.1.1 (3.d.)

Example locations observed:

1. At 12:50 pm Second floor Fairfield Wing Stair S -5 doors.

2. At 1:50 pm Third floor Fairfield Wing Stair #7 door.

C. On 08/29/2022 at 2:10pm while in the company of the DFM it was observed that delayed egress locks are installed which lack the required audible alarm. This condition does not comply with 7.2.1.6.1.1.(3) (c). Example location: California Wing Second floor inpatient unit both the Stair door and cross corridor doors.

Based on observation, not all stair components used within an exit stair are constructed to comply with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

The findings include:

A. On 08/29/2022 at 10:20am while accompanied by the DFM, Main level Exit passageway serving Stair #2 (Fairfield Wing) does not comply with 19.2.2.7, 7.2.6, 7.1.3.2 due to the following:

1. Contains three oxygen lines running the complete length.
2. Contains duct penetrations which do not appear to utilize fire dampers.
3. Contains pipe and conduit penetrations which are not sealed against smoke and fire.
4. The masonry wall between the exit stair and the passageway contains numerous holes.

B. On 08/30/2022 at 10:19am while accompanied by the DFM, Main level exit passageway serving Stair #7 contains a discharge door to the exterior sidewalk which does not latch. This condition does not comply with 7.2.1.1.1.

C. On 08/30/2022 at 9:45am while accompanied by the DFM, First floor of California Wing, East Stair (Stair #2?) contains an access panel which lacks a self closing door which does not maintain the fire resistance rating of the 2-hour enclosure and does not comply with 7.1.3.2

Based on observation fire rated separations are not provided between buildings. This deficient practice compromises the use of a horizontal exit and could affect all visitors, staff and patients when evacuating a floor or building during a fire smoke event.

Findings include:

A. On 08/29/2022 at 2:19pm while accompanied by the DFM, a minimum 2-hour fire rated horizontal exit which serves the third floor contains windows located approximately 24" from the adjacent nonrated connector bridge window wall. The adjacent nonrated exterior building wall contains patient bathroom windows less than 30" from adjacent exterior bridge wall. The angle of exposure is less than 180 degrees therefore protection of either the bridge or the adjacent building wall does not with 7.2.2.5.2.1 and 7.2.2.5.2.2 for a minimum 10'-0". Location observed: Third floor Fairfield Wing end of connector bridge.

B. On 08/29/2022 at 2:22pm while accompanied by the DFM, due to a finished opening within the Third floor Fairfield Wing Dialysis room, a minimum 2-hour fire rated barrier which serves two separate compartments does not form a complete barrier to comply with 8.3.1.2.

Based on observation, dead end corridor lengths exist which exceed permitted. This deficient practice could require a person to traverse a longer route to reach an exit and may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The finding is:

On 08/29/2022 at 3:10pm while accompanied by the DFM , the designated means of egress from the Second floor connector bridge between Fairfield Wing and California Wing, contains one designated means of egress having a length greater than allowed by 19.2.5.2. There appears to be one exit sign on the bridge which does not comply with 19.2.5.4 for a corridor having two exits.

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 lighting provided. 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.

The finding is:

On 08/30/2022 accompanied by the DFM exit discharge lights could not be determined to be 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. Not all exit discharge locations were provided with multiple fixtures (or confirmed to be fixtures with multiple lamps) to comply with 7.8.1.4.
Example locations observed:

1. At 12:10pm Exterior discharge Stair # 2 (Fairfield Wing)

2. At 12:17pm Exterior discharge Stair #2 - Gate to public sidewalk (Fairfield Wing)

3. At 12:40pm Exterior discharg Stair # 7 (Fairfield Wing)

Based upon observation, vertical openings are not protected to maintain separation of floor levels. Failure to maintain separation of floor levels can result in fire/smoke conditions migrating to other floors of the building.

Findings include:

A. On 08/30/2022 at 9:19am while in the company of the DFM it was observed that holes are present in the 2 hour fire rated shaft wall. Location observed the California Wing Second floor storage room located behind elevator car #12. This does not comply with 19.3.1 and 8.6.2 for continuous protection.

B. On 08/30/2022 at 9:21am while in the company of the DFM it was observed that an access panel to a 2 hour fire rated shaft does not comply with 19.3.1 and table 8.3.4.2 due to the following:
1. The panel is not self to comply with 8.6, and NFPA 80.
2. The panel is not secure to the frame
3. The panel does not latch to a secure position.

C. On 08\30/2022 at 11:05am while in the company of the DFM duct work penetrating a shaft wall appear to lack access panels for damper inspection. The same duct work appears to lack damper installations. This condition does not comply with NFPA 80 2010 and NFPA 90A 2012 5.3.1.1 for the presence of an access panel and the presence of a fire damper. Location observed: Basement level Boiler room

D. On 08\30/2022 at 11:07am while in the company of the DFM a shaft wall appears to contain multiple unprotected openings. The required 2-hour fire resistance rating of the shaft is compromised and does not comply with 19.2.3.2 and 8.6.2 Location observed: Basement level Boiler room

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 08/30/2022 at 9:15am while accompanied by the DFM it was identified that the Basement level Boiler room contains a corridor door which did not latch to the frame when tested and lacks a label to determine the fire resistance rating for the door. This does not comply with NFPA 101, 19.3.2 and NFPA 80, 2010.

B. On 08/30/2022 at 9:12am while accompanied by the DFM it was identified that the Basement level Boiler room is not separated from the remainder of the building due to the lack of separation at a 2-hour fire rated vertical shaft located within the Boiler room.

Based on observation that not all portions of the building fire alarm system are installed in order to provide for prompt evacuation of an area or room. This condition may prevent emergency egress from the location of fire origin to an adjacent compartment. This condition may affect patients, staff and visitors throughout the facility.

Findings include:

A. On 08/29/2022 at 1:10pm while accompanied by the DFM sleep rooms (on-call) lack an approved single station smoke alarm notification device to comply with 18.5.4.6 of NFPA 72, 2010 and 29.5.1.1(1) of NFPA 72, 2010. Example location includes the fourth floor California Wing, Staff Sleeping room.

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 of the DFM, 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 08/29/2022 at 2:05pm, while in the company of the DFM, a fire alarm manual pull station was observed that is not installed within 5' of the "Chicago Vestibule" in order to comply with NFPA 72, 2010, 17.14.6. Location observed: Third floor between the California Wing and the Fairfield Wing.

2. On 08/30/2022 at 10:05am, while in the company of the DFM, a fire alarm manual pull station was observed that is not installed within 5' of the "Chicago Vestibule" in order to comply with NFPA 72, 2010, 17.14.6. Location observed: First floor between the California Wing and the Fairfield Wing.

Based on document review and staff interview, regular testing and maintenance of a complete fire alarm system is not provided in order to aid in emergency egress from the location of fire origin to an adjacent compartment. This condition may affect patients, staff and visitors throughout the facility.

The finding is:

On 08/30/2022 at 11:00am while in the company of the DFM the review of fire alarm testing documents was determined to provide inadequate results as follows:
The Annual Fire Alarm Test dated 03/17/2022 indicated the following:
1. 88 total smoke detectors with 11 smoke detectors having failed the sensitivity test.
2. 44 total audio/visual devices (Strobes) 27 audio/visual devices failed their test.
3. 111 total heat detectors with 59 heat detectors having failed their test.
During a discussion with the facility representative it was determined that these devises have been recalled and therefore are no longer supported by the manufacturer. The facility representative stated that the facility is working on substitutions by different manufacturers. The facility failed to provide documentation demonstrating the existing fire alarm system will function as required. Further, there is no documentation pertaining to a feasibility study on the existing system or to determine how this system is being reused or updated to comply with NFPA 72, 2010, ch. 14.

Based on document review and staff interview, regular testing and maintenance of a complete fire suppression system is not provided in order to aid in emergency egress from the location of fire origin to an adjacent compartment. This condition may affect patients, staff and visitors throughout the facility.

The findings are:

A. On 08/30/2022 at 10:55am while accompanied by the DFM, the second quarter test dated 06/09/2022 indicates that "all gauges have expired. All gauges are from 2015". Therefore, the fire - sprinkler system gauges are past due for replacement. The option for testing every 5 years by a third party for comparison with a calibrated gauge to determine viability (guages are taken off the system sent to a third party for recalibration then reinstalled) is not indicated. This condition does not comply with NFPA 25, 2011, 5.3.2.1.

B. On 08/30/2022 at 11:09 am while accompanied by the DFM, the second quarter test dated 06/09/2022 indicates that "the WF in pump room feeding 1st floor North not reporting to FACP". Therefore, it appears that the flow switch may not be activating. This condition does not comply with NFPA 25, 2011, 5.3.2.1.

Based on observation the facility failed to document inspection of all facility portable fire extinguishers. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 08/30/2022 at 9:50am while accompanied by the DFM observation of the inspection tags recording the date and initials of the person completing the monthly inspection is not provided on the tag at the following date/times and locations: (NFPA 10, 2010, 7.2.1.2)

Example locations:
1. First floor IT room (California Ave. Wing) near Receiving
2. First floor Receiving (California Ave. Wing)

Based upon observation during the survey walk-thru, 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 8/29/2022 at 1:30pm while in the company of the DFM it was observed that the fourth floor California Wing Staff Sleeping room contains a corridor door which has the latching mechanism taped over to prevent the latching of the door. This condition does not comply with 19.3.6.3.5.

Based on observation, soiled linen, trash chutes and collection rooms are not protected. Trash chute collection rooms are used for purposes not related to the trash chute functions and chutes form unprotected openings between floors. 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 08/30/2022, at 9:55am while in the company of the DFM, it was observed that the Second floor linene chute door latch was taped over whih does not allow the door to close to a latched position. This condition does not comply with 19.5.4.1 for minimum 1-hour enclosure/separation of the chute.