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Based on observations, staff interview, and/or documentation on February 02/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. In the rated fire/smoke wall above the corridor doors between the NICU unit and outside the electrical room C there are two 4 inch conduit penetration with electrical cables running through them and the opening in the inside of the conduit wall and electrical is not sealed in order to maintain the required rating of the wall.

Reference NFPA 101: Table 19.1.6.1, unless otherwise permitted by NFPA 101: 19.1.6.2 through 19.1.6.7; 19.1.6.4, 19.1.6.5 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, or other features shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.
2012 NFPA 101: 19.7.6; 4.6.12.1

This deficiency affected one smoke compartment and one horizontal exiting corridor.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 02/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The chain link fence in bulk storage (part of pharmacy) had a padlock on the area.
2. The emergency release handle in the freezer in the kitchen was not able to be see in all levels of light.

Reference NFPA 101 19.2.1, 7.1.10.1 Means of egress is continuously maintained free of all obstructions to full use in case of emergency.

This deficiency affected two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 02/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Exit egress signage was not displayed from Peds ED waiting room.
2. Exit egress signage was not displayed from first floor imaging services.
3. Exit egress signage was not displayed from corridor 1049. Sign to MOB says not an exit.
4. Exit egress signage was not displayed at the end of the sub-basement center core service tunnel.
5. Exit egress signage was not displayed from the fire pump in the sub-basement.

Reference 2012 NFPA 101 Section 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.3 or 19.2.10.4.

This deficiency affected four smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 02/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The closure had been removed from the rated door to the vertical opening between floors at the end of the sub-basement service tunnel exit. The door was rated one hr, but would not self close and latch as required.

Reference NFPA 19.3.1.1 through 19.3.1.6 Vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour with one hr rated doors with slef closing devices. .

This deficiency affected two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 02/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There was not a closure on the soiled linen room, exceeding 64 gallons, in the Imaging Center.
2. There was not a closure on the soiled linen room, exceeding 64 gallons, in the Pain Clinic.

Reference 2012 NFPA 101 39.3.3.2 (1) The area shall be separated from other parts of the building by fire barriers having a minimum 1-hour fire resistance rating, with all openings therein protected by self-closing fire door assemblies having a minimum 3/4 hour fire protection rating.

This deficiency affected hazardous area and adjacent areas.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire

Based on observations, staff interview, and/or documentation on February 02/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The smoke detector in the MOB corridor was located within 3' of a HVAC supply regisiter

Reference NFPA 101 19.3.4.1, 9.6, 9.6.1.8

This deficiency affected two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 02/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Upon testing the Fire Alarm Control Panel (FACP) it was discovered that when the sprinkler control valve at the backflow preventor located outside was moved out of the normal position it provided a supervisory signal at the (FACP) but transmitted a general fire alarm to the monitoring company in place of sprinkler supervisory alarm.

Reference NFPA 101 39.3.4, 4.6.12.1; 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, or other features shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

This deficiency affected the entire facility and fire alarm panel..
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 02/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is not sprinkler coverage in the hydraulic elevator shafts.12 of 25 elevator shafts are identified by the hospital as hydraulic.

Reference 2012 NFPA 101 19.3.5.1, 9.7 19.5.3, 9.4, 2010 NFPA 13 8-15 Elevator Hoistways and Machine Rooms 8.15.5.1 Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft. (0.61 m) above the floor of the pit. 8.15.5.2 Automatic sprinklers in elevator machine rooms or at the tops of hoistway shall be of ordinary or intermediate temperature rating. 8.15.5.5 The sprinkler required at the top of the elevator hoistway by 8.15.5.4 shall not be required where the hoistway for passenger elevators is noncombustible or limited-combustible and the car enclosure materials meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators. 8.15.5.6 Sprinklers shall be installed at the top and bottom of elevator hoistway where elevators utilize polyurethane-coated steel belts or other similar combustible belt material.

This deficiency affected 12 of 25 elevator shafts that were identified as hydraulic.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 2/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The supervisory signal for the electronically supervised tamper alarm on the sprinkler control valve at the Fire Alarm Control Panel (FACP) could be silenced permanently when the valve was in the closed position.

Reference 2012 NFPA 101 Section 21.3.5.2, 9.7.2.1 Where supervised automatic sprinkler systems are required by another section of this code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, AND a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed at a location within the protected building that is constantly attended by qualified personnel.

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 2/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. This facility is 100% sprinklered per NFPA 13. The sprinkler heads located in the imaging area were not maintained clean and in good condition. Sprinkler heads were covered in dust and lint at the time of the survey.

Reference 2012 NFPA 101 39.3.5, 9.7.5, 4.6.12.1, 2011 NFPA 25.5.4.1.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, or other features shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

This deficiency affected one smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 02/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The corridor door to clean utilities room had penetrations around the handle where the latching device had been replaced. THe door was not smoke tight to resist the passage of smoke.

Reference 2012 NFPA 101 21.3.7.1 (2) Doors shall be constructed of not less than 1-3/4" thick, solid-bonded wood core or the equivalent and shall be equipped with positive latches. Reference 2012 NFPA 101 19.6.3.2 (2) The door shall be constructed to resist the passage of smoke, 4.6.12.4 CMS S&C 07-18.

This deficiency affected one smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 02/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There was a flex cable in the smoke wall by room 1216, the results room, that the penetration had not been sealed properly.

Reference 2012 NFPA 101 20.3.7.1 (1) Walls shall have not less than a 1-hour fire resistance rating and shall extend from the floor slab below to the floor or roof slab above.
Reference 2012 NFPA 101 Sections, 8.5, 8.5.6.2, 8.5.6.3, 8.5.6.5
Reference 2012 NFPA 101 Sections, 4.1.1, 4.2.3, 4.5.8, 4.6.12.2, 4.6.12.4, 43.5.1.3
Reference 2012 NFPA 101 Sections 9.1.2
Reference 2011 NFPA 70 Articles 300-21, 760-3(a), 820-26, 830-26
Reference 2012 NFPA 101 4.5.8 Smoke barriers shall be constructed to a 1/2-hour fire resistance rating.

This deficiency affected the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 2/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The door in the smoke barrier wall to the MD's Lounge had been removed.

Reference 2012 NFPA 101 21.3.7.1 (2) Doors shall be constructed of not less than 1-3/4" thick, solid-bonded wood core or the equivalent and shall be equipped with positive latches. 4.6.12.4 CMS S&C 07-18.

This deficiency affected two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire

Based on observations, staff interview, and/or documentation on February 2/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The opening in the smoke barrier door noted as room 1748, staff break room was not fire rated nor wired glass. The plans showed this door as part of the one hour smoke barrier.

Reference 2012 NFPA 101 19.3.7.6, 19.3.7.6.2, 8.5 Openings in smoke barrier doors shall be fire-rated glazing or wired glass panels in steel frames

This deficiency affected two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 02/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The electrical outlet at 5 south break room at sink, 5285 was not GFCI protected.
2. The GFCI's in bulk storage did not function properly.

Reference 2012 NFPA 19.5.1.1, 9.1.1, 9.1.2, NFPA 70, National Electric Code

This deficiency affected two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to electrical shock.

Based on observations, staff interview, and/or documentation on February 2/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The HVAC duct work did not have an service opening that would allow for the testing, inspection, maintenance, installation or cleaning of the smoke detector in the penthouse.

Reference NFPA 101 19.5.2.1, 9.2 NFPA 90A: 4.3.5.1

This deficiency affected one smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 02/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Based on observation on the sixth and seventh floor, the facility failed to limit trash/soiled linen collection receptacles in corridors to 32 gallons in capacity. Trash/Soiled linen containers were found >32 gal capacity.

Reference 2012 NFPA 101, 19.7.5.7.1 Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity and shall meet all of the following requirements:
(1) The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2).
(2) A capacity of 32 gal (121 L) shall not be exceeded within any 64 ft2 (6 m2) area.
(3)*Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
(4) Container size and density shall not be limited in hazardous areas.

This deficiency affected six smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 2/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The remote generator annunciator located at the nurse station did not provide a signal for loss of (Emergency Power Supply) EPS supplying load or a battery charger AC failure when checked.

Reference 2012 NFPA 99: 6.4.1.1.16.2 (Table item O),

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on February 02/13/2018 through 2/16/2018 the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Oxygen storage was within five feet of combustibles.

Reference 2012 NFPA 101 20.3.2.3, 99 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13.3 Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour.

This deficiency affected one smoke compartment.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.