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A. Based on random observation during the survey walk through portions of the building components are of combustible materials which does not comply with NFPA 220 1999 3-1.1

1. Location observed: Ground floor "Old Key Room", surveyor observed that this space has been subdivided with wood studs and plywood decking. This room is deemed a hazardous area by the Authority Having Jurisdiction (IDPH) due to the amount of storage within this space.

2. Location observed: Second floor 1925 building Behavioral Unit, Mens Shower adjacent to the pipe/duct chase. Surveyor observed partition wall of wood stud construction.

3. Example location observed: Second floor 1925 building Behavioral Unit, Pipe/duct chase adjacent to Mens Shower. Surveyor observed plywood decking attached to the underside of the concrete slab above. This condition was noted on every floor in multiple duct/pipe chases. The surveyor was unable to determine the use of the plywood material.. Refer to K-Tag 020 referencing the lack of a 2-hour fire rated chase enclosure.



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A. Portions of the building were observed to not be in compliance with 19.1.6.2. with respect to fire resistive construction type, as described below.

1. During an interview held in the Office of the Chief Financial Officer on the morning of June 5, 2007, the provider's Director of Support Services was not able to identify the intended UL Design for the original building's roof/ceiling assembly and floor/ceiling assemblies. Surveyor 14290 notes that the systems appear to include a plaster membrane on the underside of the open web steel joists, but that fire dampers could not be verified at all penetrations of this membrane by supply, return, or exhaust ductwork. Compliance with 19.1.6.2. could thus not be demonstrated.

2. Portions of the building were observed at which the plaster membrane had been removed from the underside of the open web steel joists, thus compromising the apparent original building construction type. Compliance with 19.1.6.2. could thus not be demonstrated. Surveyor 14290 notes that this condition appears to be prevalent throughout the building. Portions of the building where this condition was observed include:

a. Third Floor:
1) A Wing.
b. First Floor Corridor to Medical Arts Building.

3. One story portions of the building were observed to be of Type II (000) construction and to not be separated from the adjacent, higher construction type by minimum 2 hour fire rated construction as required by 19.1.1.4.1. or 19.1.6.2. Locations observed include:
a. First Floor:
UPDATE 8/19/10: at the cross corridor doors (ID7) located in the 2 hour wall, it was noted that the steel I beam above the ceiling was enclosed or protected. It was also noted that the doors located in this 2 hour rated separation did not contain fire rated hardware.

b. Corrected 8/19/10

4 Duct penetrations were observed, through the plaster membrane on the underside of the open web steel joists, that are not equipped with fire dampers that are required by the UL Design for the roof/ceiling assembly or floor/ceiling assembly and for compliance with 19.1.6.2. Locations observed include:

a. Third Floor D Wing Mechanical Room, 4 ducts (1 at each air handling unit).

UPDATE 1/7/09, Relative to item 4 above: Although existing fire dampers were observed to exist in the branch supply ducts at the presumed perimeter wall(s) of the mechanical rooms to separate the supply ducts within mechanical space from the ducts beyond the mechanical space within the above ceiling cavity, it is still not clear that a complete separation of the mechanical room from the above ceiling cavity is provided. The above ceiling cavity is utilized as a return plenum and is also part of the ceiling/roof assembly or ceiling/floor assembly. The observed fire dampers do not appear to serve to provide the required protection of the ceiling/roof or ceiling/floor assemblies. Fire dampers appear to be required where the supply ducts penetrate the ceiling membrane. The ceiling membrane needs to form a complete barrier between the mechanical space and the above ceiling cavity. Voids were observed between the ducts observed with the dampers.

A. Based on random observation during the survey walk through wood door frames including trim were noted in exit access corridor walls (non sprinklered areas of the building) which does not comply with 19.3.6.3.7. Example location:

1. Second floor 1925 building example room # 236 This is evident throughout the facility in the 1925 building. All floors contain the same type of corridor door frames withinin non sprinklered areas of the facility.



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A. Example location: Ground floor pipe shaft adjacent to "Old Key room" and east of "Styrofoam cup room". Access to the shaft is from the "Old Key room". The shaft penetrates multiple floors and lacks a 2 hour fire rated shaft enclosure. Openings are not protected as appropriate for the fire resistance rating of the barrier.
Conditions cited as follows:

1. The doors to the shaft (surveyor was told these doors were from bathrooms and allowed access to the shaft from those floor levels) do not provide a continuous separation for a shaft enclosure due to the following:

a. The door frames are combustible wood construction
b. The doors are not self closing.
c. The doors lack a fire resistant U.L. listed label for a 2-hour rated shaft enclosure.

2. The walls of the shaft contain multiple holes, and unprotected penetrations which are not sealed to maintain the fire rating of the enclosure.

3. The shaft contains multiple combustible materials within - primarily wood.


B. Example location observed: Second floor South wing of 1925 building, Pipe/duct chase enclosure adjacent to Men's shower. Vertical PVC pipe penetrations through 2-hour fire rated floor assemblies were observed that are not sealed against the passage of fire with a U.L. listed assembly at each floor penetration to comply with 8.2.3.2.4.2 This condition is prevalent throughout the facility and on every floor.


C. Example location observed: First floor pipe/duct chase access from "Data" room across from main elevators. The 2-hour fire rated enclosure for the chase is not maintained due to the following:

1. Lack of a fire resistant U.L. labeled door and frame for access.

2. The door is not self closing.
These conditions were observed throughout the facility at all locations of duct/pipe chases.



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A. Based on random observation during the survey walk-through, document review, and staff interview, not all ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. Findings include:
A representative of the provider's Consulting Engineer stated that exhaust shafts exist between the pairs of Patient Sleeping Rooms (or at individual Patient Sleeping Rooms) and that such shafts communicate between the Third and Second Floors of the building; however, penetrations through these shaft walls do not appear to be equipped with fire dampers as required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1. Surveyor 14290 notes that:

1. Based on drawing review, there appear to be approximately 24 shafts of this type.

2. Duct penetrations lacking the required fire dampers appear to exist:

a. At Second Floor Patient Toilet Room exhaust grilles.

b. At Third Floor Patient Toilet Room exhaust grilles.

c. On the Third Floor where exhaust ducts exit the shaft enclosures to gather prior to passing through the roof/ceiling assembly.
Surveyor notes that, during an interview held in the Administrative Conference Room on the morning of August 18, 2008, hospital representatives presented a sample of a damper assembly, equipped with a fusible link, that had been removed from exhaust duct within the shaft wall at a Patient Sleeping Room Toilet. It is noted that the damper is not within the plane of the wall, is not sufficiently latching, and cannot be inspected or serviced.

B. Surveyor notes that the UL Designs for the presumed ceiling/floor assemblies utilized for most areas of the building appear to include fire dampers at supply, return, and exhaust diffusers; however these fire dampers do not appear to be in place. Also refer to K-012.

A. There is a lack of clearly indicated smoke barriers on the Facility provided Life Safety Plans. It appears that the travel distance from one smoke compartment to the next exceeds the allowable maximum travel distance. Example location observed: First floor central part of building including 1968 addition.



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A From random observation the surveyor finds that multiple Hazardous Areas are not enclosed to comply with 19.3.2, and 8.4 :

1. Ground Floor Recieving Dock lacks complete fire rated separation from adjacent spaces. Surveyour observed a pair of cross corridor push style doors leading to the Dock which do not maintain a fire rated separation due to the lack of the following:

a. The doors lacked a U.L. fire rated label
b. The doors did not positively latch
c. The door frame lacked a U.L. fire rated label.
d. The doors were not self closing.


B. Multiple locations containing stored combustible materials are not separated from adjacent areas to comply with 19.3.2. Conditions and locations noted as follows:

1. Ground floor - "Stryofoam Cup room" is not designated as a hazardous area, however it is a storage room containing multiple combustibles.

2. Ground floor - Maintenance shop containing numerous combustible materials and is deemed a hazardous area lacks separation from adjacent spaces due to the following:
a. Perimeter walls do not indicate a 1-hour fire rated separation on the Life Safety plans.
b. There is no fire rated self closingdoor and frame between this room and adjacent offices or the area leading to the maintenance hallway.
c. A West wall of this area is the enclosing metal wall of the kitchen cooler. There is no indicated fire resistant rating for this installation.


3. Corrected 8/19/10




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A. Location observed: North East Stair Ground level adjacent to Kitchen "Styrofoam cup storage". Surveyor observed that the Stair is not physically separated from the exit access corridor and opens directly into it on the level of exit discharge. There is no fire resistant labeled latching door and frame. The lack of a separation does not comply with 19.3.1.1. and 7.1.3.2.1.

B. Location observed: Center North Stair 1925 building, 4th floor, Surveyor observed that a 2-hour fire resistant separation is not maintained due to the following:

1. An elevator machine room is not separated from the stair due to a wall and floor construction which does not maintain the 2-hour fire rated separation.

2. A duct penetrates through the stair in the same location as C. 1. which does not serve the stair and is not separated from the stair by a 2-hour fire resistant construction.

C. Location observed: "South Stair": Surveyor observed medgas shut off valves and a oxygen line penetrating and extending the height of the stair enclosure.

D. Corrected 8/19/10
E. Corrected 8/19/10
F. Corrected 8/19/10




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A. Surveyor observed that there are six exit stairs serving the four floor levels. It is noted that all stairs discharge to the interior of the building. The discharge for these stairs do not utilize designated exit passageways and/or comply with 7.7.2. for the minimum egress capacity permitted to discharge through areas on the level of exit discharge. Further not all stairs discharge to sprinklered routes to comply with 7.7.1.
Due to the lack of information concerning the location of smoke and fire barriers it could not be determined whether these stairs, which discharge to the interior of the building actually discharge into the same smoke compartment on the First floor or Ground Level.



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A. From random observation the surveyors find that means of egress are not readily available at all times. There are multiple locations throughout the facility in which corridors contain less than two approved exits remotely located from each other which does not comply with 19.2.5.9. Numerous corridors were observed which contain dead ends exceeding 30 feet in length. Example locations as follows:

1. First floor South end corridor adjacent to "One South" This corridor terminates at one end into the Windsor Building. The Windsor building does not share the same occupiable hours as the hospital therefore, there is no access leaving this corridor with one exit.

2. Ground floor corridor (running North/south) between ED and Radiology This corridor terminates at one end into a room (closet) , the only means of egress for this corridor is located at the North end which does not comply with 19.2.5.9.

3. Ground floor corridor (running East/west) terminates at one end into the "Hot Kitchen".

4. Ground floor corridor "Morgue back hall" terminates at one end into a pair of doors that open against egress. Further this corridor contains one directional exit sign.


B. From random observation patient care areas are open to exit access corridor (not sprinkler protected) which does not comply with 19.3.6.1. Location observed, the patient dressing area for Flouroscopy.


C. Location observed: North Stair 1954 addition, The direction of egress is not clear to the public way due to the uninterrupted continuation of the stair beyond the level of discharge. This does not comply with 7.7.3.


D. Corrected 8/19/10


E. Location observed: Ground floor Lab and Radiology which are not indicated as a Suite to comply with 19.2.5.3, therefore, occupants are required to pass through an intervening space(s) to obtain access to the exit access corridor which does not comply with 19.2.5.9. For example Microboilogy must pass through Hematology, Pathology must pass through Chemistry and Processing must pass through Fluoroscopy. These are not the only two areas, Central Supply is similar.


F. Location observed: Ground floor Recieving Dock Hallway which is indicated as an exit access corridor. This corridor does not comply with 19.2.5.9. Surveyor observed that the exiting for two stairs relies on this corridor for exiting. However, exiting is directed through the Recieving dock which is a hazardous area due to the amount of storage and multiple motorized units, this does not comply with 7.5.2.1. Refer to K-Tag 029.

G. Location observed: Ground floor Kitchen which is indicated as having two remote exits out of the area. However, one designated means of egress is shown as being through the "Styrofoam cup storage" room which is deemed a hazardous area. This does not comply with 19.3.2 and 7.5.2.1 for protection from hazardous areas.




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A. Corrected 8/19/10


B. Location observed, First floor, "Ancilla" conference room. A duct penetration through several wall assemblies and serves multiple areas was found to lack a damper installation. The duct originates in a mechanical room adjacent to the "Ancilla" conference room located on the first floor. The duct was seen to penetrate several rooms to the corridor and lackes any type of damper.

C. Locations observed, Ground floor exit passage for Stairs - 1968 South East and 1925 South. Surveyor was informed that these two stairs exit into 2-hour fire rated exit passageways. The Life Safety floor plans do not show a designation for exit passageways and these corridors do not comply with 7.1.3.2.1 and 7.1.3.2.2 for a continuous separated/protected exit to a discharge due to the following:

1. Both corridors contain multiple pipes, conduit, ductwork which is not separated by a 2-hour fire resistant separation.

2. The perimeter wall of the corridor serving the 1968 South East Stair is incomplete above the suspended acoustical tile ceiling. Surveyor was able to view along the North wall of the corridor above the ceiling to a large gap between the stair wall and the Boiler room wall. Therefore, this corridor is not separated from adjacent rooms.

3. Corrected 8/19/10




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A. Location observed: Ground floor, "Receiving Dock Hallway". Surveyor observed exit signs which directed egress through a hazardous area (the receiving dock room) and not toward an exit. This does not comply with 7.10.1.1.
UPDATE 8/19/10: New exit signs have been installed, but the hazardous area has not been separated at this time.


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A. The surveyors find, from document review and facility walk through, that there is no definitive floor plan showing the necessary elements for evacuation and areas of refuge to comply with 19.7.2.2. Life Safety floor plans provided by the facility representatives lacked clearly defined smoke compartments. Facility personnel's knowledge related to location of smoke barriers, direction of travel for exit access (dead end corridor issues) and locations and sizes of suites (to comply with 19.2.5) appeared to conflict with the provided Life Safety floor plans.

1. Locations and length of fire rated barrier walls.

2. Locations and sizes of smoke compartments.

3. Designated suites including the perimeter of the suite.

4. Sprinklered portions of the building and designated fire rated separations between sprinklered and non sprinklered areas.

5. Exit discharge enclosures designated exit passageways and their fire resistance.

6. Location and fire resistant ratings for vertical shaft enclosures including stairs, elevators, duct and pipe.

7. Designated hazardous areas and their fire resistance rating.



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A. By direct observation and staff interview not all inspectors tests and drains are pipe to drain capable of receiving the test flow. It was observed that to test, a garden hose it to be connected and routed to drain in non-compliance with NFPA 5-15.4.2. Location observed: First floor 1925 building, mechanical room adjacent to "Ancilla Room" with access through 1 South corridor, directly East of the Stair.



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A. By direct observation the facility to provide electronic supervision (tamper switches) for the two gate valves isolating the the back flow prevention device for the fire pump.



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A. Based on direct observation, the facility failed to provide a remote alarm annunciator for the fire pump at a point of constant attendance. (NFPA 20, 1999, 7-4.7)



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A. Not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. For example furnishings and equipment were observed stored in 8'-0" wide exit access corridors. These objects obstruct paths of egress which does not comply with 19.2.3.3. and 7.1.10.2.2.
Locations observed:

1. Ground floor, corridor leading to the Receiving Dock contains combustible materials which obstruct the egress width.

2. Corrected 8/19/10



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A. Based on direct observation, the facility failed to provide separation of medical gas zone control valves from supplied outlets and inlets in the Emergency Department. The zone valves are located at the nurses station. (NFPA 99, 1999, 4-3.1.2.3 (d)

B. Based on direct observation, the facility failed to provide zone valves located in accessible location in the corridor for the former Fast Track Department. The valves are installed within an office located within the department. (NFPA 99, 1999, 4-3.1.2.3 (d)



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A. Based on direct observation and staff interview, the facility failed to:

1. Corrected 8/19/10

2. Provide a remote manual emergency stop station for the emergency generator.
(NFPA 110, 1999, 3-5.5.6)

3. Remote alarm annunciators for the emergency generators at a constantly attended work station. NFPA 99, 1999, 3-4.1.1.15 (b)

4. Separation of normal and emergency power systems. The generator enclosure (room) contains two generators, emergency switchgear and distribution panels plus two normal power utility switchgear. (NFPA 110, 1999, 5-2)

5. Separation between the emergency generators and the elevator controls for the adjacent hydraulic elevator. (NFPA 99, 1999, 3-4.1.1.6)

6. Verify what the connected essential electrical system loads are and whether the rule for over 150 KVA prevails and the requirement for separate transfer switches need to be provided. Direct observation find that one transfer switch is provided for the 208 volt and one for the 480 volt generators. (NFPA 99, 1999, 3-4.2.2.1)

7. Identify all critical care electrical receptacles identified as to distribution panels and circuit number. NFPA 70, 517-19 & NFPA 99, 3-4.2.2.4 (b)




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A. The generator did not have the required 96 hours of fuel storage, NFPA 110, 1996, 3-1.2.

B. UPDATE 1/7/09: Hospitals are required to maintain a Level 1 emergency generator system. NFPA 99, 1999, 3-4.1.1.4(a) specifies that Type I essential electrical system power sources shall be classified as Type 10 (10 second interuption of power supply), Class X (greater than 48 hour run time without refueling), Level 1 (failure may result in loss of life or serious injury) generator sets per NFPA 110. NFPA 110, 3-1.2 requires that Level 1 generator sets in seismic risk areas be operational for a minimum of 96 hours without refueling. The facility is considered to be located in a seismic risk area.

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A. By direct observation the surveyor find the sewerage ejection pit has the access lids removed allowing sewer gas to escape to the interior of the building.
UPDATE 8/19/10: the pit has been covered with wood, which is not adequate.



20224


B. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.



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A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A. By direct observation and staff interview the facility failed to provide separation of the branches of the essential electrical system.



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A. Based on direct observation, the facility failed to provide phase 1 & 2 firefighter service requirements for all elevators. (A17.1, 211.3)

A) Based on random observation during the survey walk-through and staff interview, not all elevators within the facility conform with firefighters' service requirements of ANSI/ASME A17.3. All elevators within the building were observed to lack smoke detectors, located at each respective car landing, that comply with 19.5.3., 9.4.3.2., ANSI/ASME A17.3 1993 3.11.3. and ANSI/ASME A171. 1993 211.3b. During an interview held in the Elevator Lobby on the afternoon of September 13, 2006, the provider's Director of Support Services confirmed this observation.

A. Based on random observation during the survey walk through portions of the building components are of combustible materials which does not comply with NFPA 220 1999 3-1.1

1. Location observed: Ground floor "Old Key Room", surveyor observed that this space has been subdivided with wood studs and plywood decking. This room is deemed a hazardous area by the Authority Having Jurisdiction (IDPH) due to the amount of storage within this space.

2. Location observed: Second floor 1925 building Behavioral Unit, Mens Shower adjacent to the pipe/duct chase. Surveyor observed partition wall of wood stud construction.

3. Example location observed: Second floor 1925 building Behavioral Unit, Pipe/duct chase adjacent to Mens Shower. Surveyor observed plywood decking attached to the underside of the concrete slab above. This condition was noted on every floor in multiple duct/pipe chases. The surveyor was unable to determine the use of the plywood material.. Refer to K-Tag 020 referencing the lack of a 2-hour fire rated chase enclosure.



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A. Based on random observation during the survey walk through wood door frames including trim were noted in exit access corridor walls (non sprinklered areas of the building) which does not comply with 19.3.6.3.7. Example location:

1. Second floor 1925 building example room # 236 This is evident throughout the facility in the 1925 building. All floors contain the same type of corridor door frames withinin non sprinklered areas of the facility.



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A. Example location: Ground floor pipe shaft adjacent to "Old Key room" and east of "Styrofoam cup room". Access to the shaft is from the "Old Key room". The shaft penetrates multiple floors and lacks a 2 hour fire rated shaft enclosure. Openings are not protected as appropriate for the fire resistance rating of the barrier.
Conditions cited as follows:

1. The doors to the shaft (surveyor was told these doors were from bathrooms and allowed access to the shaft from those floor levels) do not provide a continuous separation for a shaft enclosure due to the following:

a. The door frames are combustible wood construction
b. The doors are not self closing.
c. The doors lack a fire resistant U.L. listed label for a 2-hour rated shaft enclosure.

2. The walls of the shaft contain multiple holes, and unprotected penetrations which are not sealed to maintain the fire rating of the enclosure.

3. The shaft contains multiple combustible materials within - primarily wood.


B. Example location observed: Second floor South wing of 1925 building, Pipe/duct chase enclosure adjacent to Men's shower. Vertical PVC pipe penetrations through 2-hour fire rated floor assemblies were observed that are not sealed against the passage of fire with a U.L. listed assembly at each floor penetration to comply with 8.2.3.2.4.2 This condition is prevalent throughout the facility and on every floor.


C. Example location observed: First floor pipe/duct chase access from "Data" room across from main elevators. The 2-hour fire rated enclosure for the chase is not maintained due to the following:

1. Lack of a fire resistant U.L. labeled door and frame for access.

2. The door is not self closing.
These conditions were observed throughout the facility at all locations of duct/pipe chases.



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A. There is a lack of clearly indicated smoke barriers on the Facility provided Life Safety Plans. It appears that the travel distance from one smoke compartment to the next exceeds the allowable maximum travel distance. Example location observed: First floor central part of building including 1968 addition.



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A From random observation the surveyor finds that multiple Hazardous Areas are not enclosed to comply with 19.3.2, and 8.4 :

1. Ground Floor Recieving Dock lacks complete fire rated separation from adjacent spaces. Surveyour observed a pair of cross corridor push style doors leading to the Dock which do not maintain a fire rated separation due to the lack of the following:

a. The doors lacked a U.L. fire rated label
b. The doors did not positively latch
c. The door frame lacked a U.L. fire rated label.
d. The doors were not self closing.


B. Multiple locations containing stored combustible materials are not separated from adjacent areas to comply with 19.3.2. Conditions and locations noted as follows:

1. Ground floor - "Stryofoam Cup room" is not designated as a hazardous area, however it is a storage room containing multiple combustibles.

2. Ground floor - Maintenance shop containing numerous combustible materials and is deemed a hazardous area lacks separation from adjacent spaces due to the following:
a. Perimeter walls do not indicate a 1-hour fire rated separation on the Life Safety plans.
b. There is no fire rated self closingdoor and frame between this room and adjacent offices or the area leading to the maintenance hallway.
c. A West wall of this area is the enclosing metal wall of the kitchen cooler. There is no indicated fire resistant rating for this installation.


3. Corrected 8/19/10




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A. Location observed: North East Stair Ground level adjacent to Kitchen "Styrofoam cup storage". Surveyor observed that the Stair is not physically separated from the exit access corridor and opens directly into it on the level of exit discharge. There is no fire resistant labeled latching door and frame. The lack of a separation does not comply with 19.3.1.1. and 7.1.3.2.1.

B. Location observed: Center North Stair 1925 building, 4th floor, Surveyor observed that a 2-hour fire resistant separation is not maintained due to the following:

1. An elevator machine room is not separated from the stair due to a wall and floor construction which does not maintain the 2-hour fire rated separation.

2. A duct penetrates through the stair in the same location as C. 1. which does not serve the stair and is not separated from the stair by a 2-hour fire resistant construction.

C. Location observed: "South Stair": Surveyor observed medgas shut off valves and a oxygen line penetrating and extending the height of the stair enclosure.

D. Corrected 8/19/10
E. Corrected 8/19/10
F. Corrected 8/19/10




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A. Surveyor observed that there are six exit stairs serving the four floor levels. It is noted that all stairs discharge to the interior of the building. The discharge for these stairs do not utilize designated exit passageways and/or comply with 7.7.2. for the minimum egress capacity permitted to discharge through areas on the level of exit discharge. Further not all stairs discharge to sprinklered routes to comply with 7.7.1.
Due to the lack of information concerning the location of smoke and fire barriers it could not be determined whether these stairs, which discharge to the interior of the building actually discharge into the same smoke compartment on the First floor or Ground Level.



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A. From random observation the surveyors find that means of egress are not readily available at all times. There are multiple locations throughout the facility in which corridors contain less than two approved exits remotely located from each other which does not comply with 19.2.5.9. Numerous corridors were observed which contain dead ends exceeding 30 feet in length. Example locations as follows:

1. First floor South end corridor adjacent to "One South" This corridor terminates at one end into the Windsor Building. The Windsor building does not share the same occupiable hours as the hospital therefore, there is no access leaving this corridor with one exit.

2. Ground floor corridor (running North/south) between ED and Radiology This corridor terminates at one end into a room (closet) , the only means of egress for this corridor is located at the North end which does not comply with 19.2.5.9.

3. Ground floor corridor (running East/west) terminates at one end into the "Hot Kitchen".

4. Ground floor corridor "Morgue back hall" terminates at one end into a pair of doors that open against egress. Further this corridor contains one directional exit sign.


B. From random observation patient care areas are open to exit access corridor (not sprinkler protected) which does not comply with 19.3.6.1. Location observed, the patient dressing area for Flouroscopy.


C. Location observed: North Stair 1954 addition, The direction of egress is not clear to the public way due to the uninterrupted continuation of the stair beyond the level of discharge. This does not comply with 7.7.3.


D. Corrected 8/19/10


E. Location observed: Ground floor Lab and Radiology which are not indicated as a Suite to comply with 19.2.5.3, therefore, occupants are required to pass through an intervening space(s) to obtain access to the exit access corridor which does not comply with 19.2.5.9. For example Microboilogy must pass through Hematology, Pathology must pass through Chemistry and Processing must pass through Fluoroscopy. These are not the only two areas, Central Supply is similar.


F. Location observed: Ground floor Recieving Dock Hallway which is indicated as an exit access corridor. This corridor does not comply with 19.2.5.9. Surveyor observed that the exiting for two stairs relies on this corridor for exiting. However, exiting is directed through the Recieving dock which is a hazardous area due to the amount of storage and multiple motorized units, this does not comply with 7.5.2.1. Refer to K-Tag 029.

G. Location observed: Ground floor Kitchen which is indicated as having two remote exits out of the area. However, one designated means of egress is shown as being through the "Styrofoam cup storage" room which is deemed a hazardous area. This does not comply with 19.3.2 and 7.5.2.1 for protection from hazardous areas.




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A. Corrected 8/19/10


B. Location observed, First floor, "Ancilla" conference room. A duct penetration through several wall assemblies and serves multiple areas was found to lack a damper installation. The duct originates in a mechanical room adjacent to the "Ancilla" conference room located on the first floor. The duct was seen to penetrate several rooms to the corridor and lackes any type of damper.

C. Locations observed, Ground floor exit passage for Stairs - 1968 South East and 1925 South. Surveyor was informed that these two stairs exit into 2-hour fire rated exit passageways. The Life Safety floor plans do not show a designation for exit passageways and these corridors do not comply with 7.1.3.2.1 and 7.1.3.2.2 for a continuous separated/protected exit to a discharge due to the following:

1. Both corridors contain multiple pipes, conduit, ductwork which is not separated by a 2-hour fire resistant separation.

2. The perimeter wall of the corridor serving the 1968 South East Stair is incomplete above the suspended acoustical tile ceiling. Surveyor was able to view along the North wall of the corridor above the ceiling to a large gap between the stair wall and the Boiler room wall. Therefore, this corridor is not separated from adjacent rooms.

3. Corrected 8/19/10




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A. Location observed: Ground floor, "Receiving Dock Hallway". Surveyor observed exit signs which directed egress through a hazardous area (the receiving dock room) and not toward an exit. This does not comply with 7.10.1.1.
UPDATE 8/19/10: New exit signs have been installed, but the hazardous area has not been separated at this time.


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A. The surveyors find, from document review and facility walk through, that there is no definitive floor plan showing the necessary elements for evacuation and areas of refuge to comply with 19.7.2.2. Life Safety floor plans provided by the facility representatives lacked clearly defined smoke compartments. Facility personnel's knowledge related to location of smoke barriers, direction of travel for exit access (dead end corridor issues) and locations and sizes of suites (to comply with 19.2.5) appeared to conflict with the provided Life Safety floor plans.

1. Locations and length of fire rated barrier walls.

2. Locations and sizes of smoke compartments.

3. Designated suites including the perimeter of the suite.

4. Sprinklered portions of the building and designated fire rated separations between sprinklered and non sprinklered areas.

5. Exit discharge enclosures designated exit passageways and their fire resistance.

6. Location and fire resistant ratings for vertical shaft enclosures including stairs, elevators, duct and pipe.

7. Designated hazardous areas and their fire resistance rating.



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A. By direct observation and staff interview not all inspectors tests and drains are pipe to drain capable of receiving the test flow. It was observed that to test, a garden hose it to be connected and routed to drain in non-compliance with NFPA 5-15.4.2. Location observed: First floor 1925 building, mechanical room adjacent to "Ancilla Room" with access through 1 South corridor, directly East of the Stair.



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A. By direct observation the facility to provide electronic supervision (tamper switches) for the two gate valves isolating the the back flow prevention device for the fire pump.



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A. Based on direct observation, the facility failed to provide a remote alarm annunciator for the fire pump at a point of constant attendance. (NFPA 20, 1999, 7-4.7)



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A. Not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. For example furnishings and equipment were observed stored in 8'-0" wide exit access corridors. These objects obstruct paths of egress which does not comply with 19.2.3.3. and 7.1.10.2.2.
Locations observed:

1. Ground floor, corridor leading to the Receiving Dock contains combustible materials which obstruct the egress width.

2. Corrected 8/19/10



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A. Based on direct observation, the facility failed to provide separation of medical gas zone control valves from supplied outlets and inlets in the Emergency Department. The zone valves are located at the nurses station. (NFPA 99, 1999, 4-3.1.2.3 (d)

B. Based on direct observation, the facility failed to provide zone valves located in accessible location in the corridor for the former Fast Track Department. The valves are installed within an office located within the department. (NFPA 99, 1999, 4-3.1.2.3 (d)



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A. Based on direct observation and staff interview, the facility failed to:

1. Corrected 8/19/10

2. Provide a remote manual emergency stop station for the emergency generator.
(NFPA 110, 1999, 3-5.5.6)

3. Remote alarm annunciators for the emergency generators at a constantly attended work station. NFPA 99, 1999, 3-4.1.1.15 (b)

4. Separation of normal and emergency power systems. The generator enclosure (room) contains two generators, emergency switchgear and distribution panels plus two normal power utility switchgear. (NFPA 110, 1999, 5-2)

5. Separation between the emergency generators and the elevator controls for the adjacent hydraulic elevator. (NFPA 99, 1999, 3-4.1.1.6)

6. Verify what the connected essential electrical system loads are and whether the rule for over 150 KVA prevails and the requirement for separate transfer switches need to be provided. Direct observation find that one transfer switch is provided for the 208 volt and one for the 480 volt generators. (NFPA 99, 1999, 3-4.2.2.1)

7. Identify all critical care electrical receptacles identified as to distribution panels and circuit number. NFPA 70, 517-19 & NFPA 99, 3-4.2.2.4 (b)




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A. By direct observation the surveyor find the sewerage ejection pit has the access lids removed allowing sewer gas to escape to the interior of the building.
UPDATE 8/19/10: the pit has been covered with wood, which is not adequate.



20224


B. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.



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A. By direct observation and staff interview the facility failed to provide separation of the branches of the essential electrical system.



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A. Based on direct observation, the facility failed to provide phase 1 & 2 firefighter service requirements for all elevators. (A17.1, 211.3)