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Based on observation during the survey walk-thru, wall ratings and functions in the means of egress are not clearly identifiable. This deficient practice could affect patients, staff and visitors if the facility failed to provide accurate separation during an emergency event.

Findings include:

A. On 11/1/17 at 11:00 AM while in the company of the FM it was observed that the 1st floor of the West Pavilion, contains a building separation from the main building by elevator 35. The wall is stenciled above the cross corridor doors "2 hour" fire rating. However, the facility provided Life Safety Code drawings indicate that the wall is only a smoke partition. It was unclear if the wall has been maintained in accordance with 19.1.1.4.1 and 7.2.4.3 for a horizontal exit.


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B. On 11/01/2017 at 12:50 PM while in the company of the MRC during a review of the facility provided Life Safety floor plans indicates that a pair of cross corridor doors on the north side which separate the atrium from the remainder of the 1st floor level are part of a non fire rated smoke barrier which does not comply 19.3.1.1 for a minimum 1-hour fire rating.

C. On 10/31/2017 at 1:10 PM while in the company of the MRC during a review of the facility provided Life Safety floor plans it was observed that locations are referred to as "suites" however, these areas do not comply with 19.2.5.7 for qualifying suites which are patient sleeping suites or patient care non-sleeping suites. Example locations:

1. Ground floor Lab
2. Ground floor Pharmacy
3. Ground floor Sterile Supply

Based on observations the facility failed to provide a building with an acceptable construction type. This deficient practice could affect patients, staff and visitors if a fire in the deficient area were to compromise the buildings structural integrity during a fire emergency.

Findings include:

On 11/01/2017 at 10:05 AM, while accompanied by the SO, it was observed a support beam which lacks fire proofing on the bottom flange. The beam is located in the Basement Electrical Room of the North Building. This does not comply with Table 19.1.6.1 and NFPA 220 2012 Ed. Table 4.1.1.

Based on observation during the survey walk-thru, means of egress are not maintained to provide protected and unimpeded paths to exits. This deficient practice could affect patients, staff and visitors if a failure to provide required paths compromise access and level of safety for occupants.

Findings include:

A. On 11/1/17 at 10:10 AM while in the company of the FM it was observed that the 1st floor of the West Pavilion, Critical Care unit corridors contained chairs at remote nursing stations as well as equipment carts that were unattended. The stationing of these materials in the corridor reduces the available width of the corridor and does not comply with the requirements of 19.2.3.5.


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B. On 11/1/2017 at 10:10 AM while in the company of the MRC, the semi-restricted corridor surrounding the O.R.'s in the Surgery Dept. contain gurneys, surgical equipment, soiled linen bins, located along both sides of the means of egress corridor. The number of gurneys exceeded that which would be "in-use" outside of one typical Operating room. This condition does not comply with 19.2.3.3.

C. On 11/1/2017 at 10:20 AM while in the company of the MRC, corridor #1818 as shown on the facility provided Life Safety floor plans and located between Surgery and Recovery, contains equipment and shelving units which obstructs the use of the exit door at the end of the corridor which does not comply with 19.2.3.

Based on observation during the survey walk-through, not all egress doors are installed or maintained to permit egress. This deficiency may affect any staff, patients and visitors because they could be prevented from exiting those areas under emergency conditions.

Findings include:

A. On 10/31/17 at 3:35 PM, while accompanied by the FM, the door on to the 5th Floor from the South East elevator lobby is locked after hours. Securing entry on to the floor does not comply with 19.2.2.2.4. There is no means of escape from the elevator lobby area. The wall phone and break glass arrangement does not meet the exceptions of 7.2.1.6.3 for elevator lobby door.

B. On 11/1/17 at 2:18 PM, while accompanied by the FM, the door from the 3rd Floor South West elevator lobby (containing toilet room 3427) and exit stairs are locked after hours. Securing exiting from the floor to the designated exit stairs does not comply with 19.2.2.2.4. The doors at this location require either a card swipe or "break glass" button lock bypass which does not comply with 7.2.1.5.6 access controlled doors.


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C. On 10/31/2017 at 2:55 PM, while accompanied by the SO, the 2nd Floor of the Outpatient Sleep Lab, North Building, contains designated exit signs that direct the path of egress from the Sleep Lab corridor into the Outpatient Behavioral Unit. The facility representative stated that these doors are provided with " in-active" magnetic locking devices. These doors have the ability to be locked against egress. This does not comply with 19.2.2.2.5 and 7.2.1.6.2 for access control.


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D. On 11/01/2017 at 2:30 PM while accompanied by the MRC, it was observed that a horizontal sliding door does not comply with 19.2.2.2 for the latching requirements of a corridor door. The location observed is the 1st floor Emergency Dept - south wall of corridor #1449 (Life safety floor plan).

Based on observation during the survey walk-through, not all stair components used within an exit stair are constructed to provide a safe enclosure. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. During the survey walk through while accompanied by the MRC, guardrails and handrails for existing exit stairs were observed to not comply with 19.2.2.3, 7.2.2.4.1.1 and 7.2.2.4.2. The following are example locations:

1. 10/31/2017 at 2:10 PM Exit Stair #9.

2. 10/31/2017at 1:20 PM Exit Stair location referred to as on the 1st floor, #3 Building, Door # 29.

Based on observation during the survey walk through, not all egress paths lead to an exit. This deficient practice could require a person to traverse a longer route to reach an exit. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The finding is:

On October 31, 2017 at 2:10 PM while accompanied by the MRC, the designated means of egress (exit sign above door) from the ground floor corridor (#G841 on the facility provided Life Safety floor plan) from the tower building was observed leading into the Loading Dock material break down area (Stor #839). This area contains numerous impediments to a safe means of egress and is deemed a hazardous area on the Life Safety floor plan. Exiting into this hazardous area does not comply with 19.2.2.5 and 19.1.3.7.

Based on observation during the survey walk-through, designated suites are in excess of the maximum size allowed. This deficiency could affect any staff, patients and visitors under emergency conditions from exiting those areas in a timely manner.

The finding is:

On 11/01/2017 at 2:20 PM while accompanied by the MRC, a non-sleeping patient care suite exceeded the maximum allowable size to comply with 19.2.5.7.3.3. Location observed: Emergency Department

Based on observation during the survey walk-through, not all means of egress meet the required travel distances. This deficiency could affect any staff, patients and visitors because the excessive travel distance could prevent exiting those areas in a timely manner under emergency conditions.

The finding is:

On 11/1/17 at 10:00 AM, while accompanied by the FM, the South Corridor of the west pavilion exceeds 300 feet in length without any identified alternate means of egress from this corridor. The travel distance within this corridor exceeds the maximum travel allowed by 19.2.6.2.1 and 19.2.6.2.2.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

The findings are:

A. On 11/01/2017 at 2:15 PM while accompanied by the FM exit signage was observed by which the facility referred to as "way finding signage" within the 1st floor ICU/CCU corridors that do not comply with 7.10.1.2.1, 7.10.1.8 and 7.10.2.

B. On 11/01/2017 at 1:15 PM while accompanied by the FM the word "exit" was observed painted on a wall located on the 3rd floor exit door from the Birthing Unit to the West Pavilion that does not comply with 7.10.1.8 and 7.10.1.9.


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C. On 11/01/17 at 2:50 PM, while accompanied by the SO only one path of exit access was observed to be identified by exit signage. This does not comply with 19.2.5.4. Location observed: North Pavilion, 3 - West corridor adjacent to the East Dining room.


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D. On 11/01/2017 at 2:10 PM while accompanied by the MRC only one path of exit access was observed to be identified by exit signage which does not comply with 19.2.5.4. Location observed: 1st floor corridor adjacent to the Emergency Dept. looking toward the south end of the corridor.

E. On 10/31/2017 at 2:20 PM while accompanied by the MRC exit signage was observed in the Ground level Pharmacy (designated as hazardous) which directed a person into two clean rooms. Both doors contain signs reading "emergency exit only alarm will sound". This configuration does not comply with 19.2.10 and 7.10.1.2.

F. On 10/31/2017 at 1:30 PM while accompanied by the MRC exit signage was observed in the Ground floor level Lab through a conference room, staff lounge and staff locker room to a means of egress corridor which does not comply with 19.2.10 for travel distances and intervening rooms.

G. On 11/01/2017 at 1:45 PM while accompanied by the MCR exit signage is obstructed from view and does not comply with 7.10.1.8. Location observed, Pre-Op outpatient, exiting toward the O.R.'s - the sign is obstructed by room signage.

Based upon observation, vertical openings are not constructed and maintained to provide separation of floor levels in accordance with requirements. Failure to protect vertical openings can permit the effects of a fire/smoke event to expose and compromise the safety of occupants on other floor levels.

The findings are:

A. On 11/01/2017 at 9:30 AM while accompanied by the MRC it was observed that the atrium contained areas which do not comply with the requirements of an atrium/vertical opening due to the following:

1. The indicated 1-hour fire rated glass wall at Surgery Waiting #G101 ground floor level (as provided on the facility Life Safety floor plan) contain a pair of doors with electric strikes. These doors do not comply with the latching requirements of a 1-hour fire rated enclosure of a vertical opening under fire alarm conditions these doors are to be latching doors 19.3.1.1.

2. The facility provided Life Safety floor plan indicates various areas/rooms which are open to and therefore part of the atrium. However, these areas do not comply with the requirements of 8.6.7 (1). The following areas (as provided on the facility Life Safety floor plan) are part of the atrium space, however, these areas are not defined by an engineering analysis as being included or requiring separation. The areas are, 1st floor men's and women's toilet rooms, corridor adjacent to these toilet rooms along with approximately 3 offices and corridor #1759.

B. On 10/31/2017 at 3:10 PM while accompanied by the MRC it was observed that Stair #9 (ground to 5th floor) contains a condition prevents persons from exiting in the direction of the discharge level which does not comply with 7.7.3.4.

Based on observation during the survey walk-through, the enclosures for all hazardous areas are not complete as required. These deficiencies could affect any patients, staff, or visitors in the area because fire and smoke could move from them to other occupied portions of the building.

Findings include:

A. On 11/1/17 at 8:50 AM, while accompanied by the FM, in the West Pavilion on 4th floor soiled utility room 4066 contained a large duct penetration (hole was approximately 3'x3') and a conduit penetration through the "blaze frame" rated wall system that were not sealed against the passage of fire as required by 19.3.2 and 8.3.5.

B. On 11/1/17 at 9:30 AM, while accompanied by FM, in the West Pavilion on 3rd floor soiled utility room 3047 contained a conduit which penetrated both a smoke wall into the medication room and the 1 hour rated wall into the clean holding room which were not sealed in accordance with 19.3.2 and 8.3.5.


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Based upon direct observation, sprinklered hazardous areas are not separated by a minimum of smoke resisting construction. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

Findings include:

C. On 11/1/ 2017 while in the company of the MRC areas were observed being used for the storage of equipment, supply carts, gurneys and bassinets in quantities greater than that for the normal area's function. Example locations:

1. At 9:35am 1st Floor SCP area is being used as storage. Approximately 8 gurneys 1 bassinet and multiple pieces of equipment are being stored. This room is being used as storage of items in quantities greater than that for its original use. This room does not contain a self closing door and does not comply with 19.3.2.1, 8.7.1 & 8.4.

2. At 9:45 1st floor Dialysis rooms/bays #11, #4, #3 used as storage, doors do not comply with 19.3.2.1 and 8.7.1 for self closing actions.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's exit access corridors.

The Finding is:

On 11/01/17 at 1:50 PM while accompanied by the SO, the surveyor observed, the 1st floor contained Soiled Utility enclosure with openings around pipe penetrations which are not sealed to be smoke-tight walls to comply with 21.3.2 and 39.3.2.1.

Base on observation the facility failed to separate the kitchen grease duct from environmental ventilation ducts within the fire rated enclosing shaft. This deficient practice could result in the uncontrolled spread of fire and products of combustion during a kitchen hood/duct fire event, which may affect patients, staff and visitors.

The findings are:

A. On 11/1/17 at 3:30 PM accompanied by the DF and the MRC, it was observed at the second floor duct shaft (2542) that the kitchen grease duct is enclosed within the same shaft as supply air ventilation ducts which does not comply with NFPA 90A, 2012, 5.3.4.5.

B. On 11/1/17 at 3:30 PM accompanied by the DF and the MRC, it was observed at the second floor duct shaft (2542) that the kitchen grease duct plastered duct insulation was deteriorating which does not comply with NFPA 90A, 2012, 5.3.4.5.

C. On 11/1/17 at 3:30 PM accompanied by the DF and the MRC, it was observed that the second floor duct shaft (2542) contains the aluminum dishwasher exhaust duct which is showing signs of corrosion and degradation allowing moisture to drip onto the grease duct insulation underneath contributing to further deterioration which does not comply with NFPA 90A, 2012, 5.3.4.5.

Based on observation the facility to provide complete smoke detection. This deficient practice could result in the untimely notification of fire which may affect patients, staff and visitors.
A. On 11/1/17 at 10:45 AM accompanied by the DF, it was observed that a single station smoke alarm and visual notification appliance has not been installed within the Emergency Department On-Call sleep room (1560). /NFPA 72, 2010, 18.5.4.6.


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B. On 11/01/2017, while accompanied by SO, the surveyor observed several smoke detectors that were located less than 3-feet from a mechanical supply vent. NFPA 101, section 9.6, NFPA 70 and NFPA 72 2010 Edition, Section 17.7.3.1.
Locations observed include:

1. At 9:00 AM, North Pavilion, Basement Floor exit access corridor leading to the Main Hospital.
2. At 10:19 AM, Main Building, Fourth Floor exit access corridor by the West Building.


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Based on observation during the survey walk-through, not all portions of the building's fire alarm system are installed and maintained as required. This deficient practice could affect patients, staff, or visitors in the building because the fire alarm system could fail to activate under emergency conditions if the components are not properly installed and maintained.

the finding is:

C. On October 31, 2017 at 1:25 PM while in the company of the MRC it was observed that a fire alarm manual pull station was not provided within 5' of the exit stair #1 door from ground floor corridor ( adjacent to Lab staff lockers) in order to comply with NFPA 72-2010, 17.14.6.

Based on an observation and interview, the facility failed to install all required initiating devices to provide a properly functioning fire alarm system. This deficient practice could affect patients, staff and visitors if smoke was not detected and the fire alarm system does not operate properly due to smoke detector placement.

The finding is:

A. On 11/01/2017, while accompanied by SO, the surveyor observed several smoke detectors that were located less than 3-feet from a ceiling supply vent. This condition does not comply with Section 9.6, NFPA 70, 2011 Edition and NFPA 72, 2010 Edition, Section 17.7.3.1.

Locations observed include:

1. At 1:55 PM, Clean Storage.
2. At 1.57 PM, Soiled Utility.
3. At 2:00 PM, Break Room.
4. At 2:05PM, Lab.

Based on observation during the survey walk-through not all portions of the facility's automatic sprinkler system are properly installed and maintained. The installation of furnishings can result in delayed sprinkler activation by not having the sprinkler heads located within the heat capture zone and could affect any patients, staff, or visitors in the area.

Finding is:

A. On 11/1/17 at 10:20 AM while in the company of the FM it was observed that the 1st floor West Pavilion, Critical Care unit Room 24, that the side wall sprinkler installed between the retracted patient curtain and a wall mounted television restrict sprinkler discharge pattern. This does not comply with NFPA 13, 8.7.5.1 and 8.7.5.2.2

B. On 10/31/2017, while accompanied by the SO, the surveyor finds that escutcheon plates for sprinkler heads were missing. This does not comply with NFPA 13 2010. Locations observed include:

1. At 2:30 PM, North Pavilion, Second Floor (West Side), SPO II (File Room).
2. At 10:00 AM, North Pavilion, Basement, DEP Simulation Lab Closet.

C. On 11/01/2017 at 9:35 AM, while accompanied by the SO, the surveyor finds that the sprinkler head was missing in an otherwise sprinklered smoke compartment. This does not comply with NFPA 13 2010.
Location observed, North Pavilion, Basement Floor, Mechanical Room at the Telecom Closet near the Electrical Meter Room.


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Based on observation during the survey walk through the facility failed to install all require components of the wet pipe fire suppression system. Failure to install and maintain these systems could result in malfunction and delayed response. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

D. On 10/31/17 at 1:40 PM accompanied by the DF, it was observed in the elevator machine room for elevator #6 that an automatic flow switch test system had been installed for the flow switch for this portion of the fire protection sprinkler system. The required test and drain has not been installed as required by NFPA 13, 2010, 8.17.4.2 and as required for testing by NFPA 25, 2011, 5.3.3.3.

E. On 11/1/17 at 10:45 AM accompanied by the DF, it was observed in the Emergency Department Waiting Room 3 sky lights approximately 6 feet square by 5 feet deep are without sprinkler fire protection. NFPA 13, 2010,8.6.7


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F. The means of egress corridor located adjacent to each OR contains soffited gurney alcoves with the alcove ceilings lower than the corridor ceilings. The alcoves are not provided with sprinkler protection to comply with NFPA 13 2010 8.1.

Based on observation not all exit access corridors are separated from use areas. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke to enter the egress corridor.

Findings include:

A. On 11/01/2017 at 8:40 AM, while accompanied by the SO during the survey walk-through, the Cancer Care Center, First Floor, Men's and Women's Gowned Waiting areas are open to the adjacent corridor and lack smoke detectors. This does not comply with the 19.3.6.1.1 a).

B. On 11/01/2017 at 8:30 AM, while accompanied by the SO during the survey walk-through, the Patient Holding area on the First Floor of the Cancer Building, is open to the corridor. This condition does not comply with the 19.3.6.1.1 a).

C. On 10/31/2017 at 2:00 PM, while accompanied by the SO during the survey walk-through, the surveyor observed a Waiting Area in the Second Floor of the Behavioral Outpatient Services. The configuration of furniture obstructs the required corridor width. This does not comply with the requirements of 19.3.6.1.1 c).

Based on observation during the survey walk-thru and review of the facility's life safety reference drawings, Corridor doors are not properly installed to latch. This deficient practice could affect patients, staff and visitors if failure of the corridor doors and the means of keeping the door closed compromises the means of egress corridor intended to provide a protected path of egress to an exit.

Finding include:

On 11/1/17 at 10:20 AM while in the company of the FM it was observed that the 1st floor West Pavilion, Critical Care unit, the sliding doors from the corridor to the patient rooms were not put into motion easily and the door latch failed to function to comply with 19.3.6.3.5 (1)

Based on observation during the survey walk-through, not all designated two hour enclosure areas are maintained and protected. These deficiencies could result in the effects of fire and smoke from one room, transferring to adjacent occupied smoke compartment and compromising the safety of patients, staff and visitors during a fire/smoke event.

The finding is:

On 11/01/2017 at 9:15 AM, while accompanied by the SO, at the Cancer Care Center, Basement Floor it was observed that a supply/exhaust duct from the Mechanical Room C0017A penetrating the designated two hour wall of the adjacent Electrical Room could not be confirmed to have a fire damper to comply with 19.5.2.1, 9.2.1 and NFPA 90A-1999, 3-3.4.4 because no access door was provided in accordance with NFPA 90A-1999, 2-3.4.

Based on observation during the survey walk through the facility failed to correctly install components for the elevator firefighter service and recall systems. Failure to install and maintain these systems could result in malfunction and response of the recall function. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:
On 10/31/17 at 1:30 PM accompanied by the DF, it was observed in the elevator machine rooms for elevators #'s 6, 10 &11 that heat detector are not installed within 2 feet of the sprinkler head for elevator shutdown. This does not comply with 19.5.3 / ANSI A17.1, 2007, 2.8.3.3.2 & NFPA 72, 2010, 21.4.2.

Based upon observation, the smoke control system for the building atrium is not maintained in accordance with Code requirements. Failure to maintain the building's smoke control system can permit the effects of a fire/smoke event to expose and compromise the safety of occupants on other floor levels.

Findings include:

A. On 11/01/2017 at 1:10pm while accompanied by the MRC during a discussion concerning the building's atrium it was noted that documentation is to be provided regarding the testing of the smoke control system to comply with NFPA 92 2012, 8.6 for semiannual testing and for the testing documentation. Findings include:

1. Current documentation is dated 03/03/16 which does not comply with 8.6. for testing frequency.

2. Testing documentation dated 03/03/16 contains references to the following system deficiencies:
a. Atrium barrier walls fire stopping at the doors at the east end of corridor 1759 remains uncorrected.
b. Three ground floor fire doors require adjustment to provide proper latching/relatching. One set of doors requires adjustment in order to provide less than 15lbs required to open door. One crash bar at the fire door in corridor 1759 did not unlatch the door.
c. The TAB report indicates total CFM at 23,463. However, only 18,897 CFM is noted at the exhaust inlet grilles in the atrium. It appears there may be leaks in the duct or dampers serving this system.

Based on observations, the facility failed to provide proper medical gas identifications. This deficient practice could affect patients, staff and visitors if proper piping is not labeled.

The finding is:

On 11/01/2017 at 9:00 AM, while accompanied by the MRC, it was determined that the 1st floor corridor outside of Dialysis contains a medical gas shut off valve labeled "Day Hospital". This area could not be identified and the surveyor was informed no longer exists under that title. Therefore, the shut off valve does not comply with NFPA 99, 2012.

Based on observations, the facility failed to provide proper electrical identifications in electrical areas. This deficient practice could affect patients, staff and visitors if proper electrical circuit is not labeled.

The finding is:

A. On 11/01/2017 at 9:00 AM, while accompanied by the SO, it was determined that on the Basement of the Cancer Building, Electrical Room /Fire Alarm Room, an identified electrical panel CLP-CC directory is not updated. This does not comply with the requirements of NFPA 70, 2011 edition, section 408.4.


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Based upon observation, electrical systems are not installed and maintained in accordance with Code requirements. Failure to install and maintain the building's electrical systems can result in electrical shock hazards or loss of essential power for life support or means of egress lighting.

Findings include:

B. On 11/01/at 8:55am while in the company of the MRC it was determined that electrical panels contain mixed electrical loads supplying both Life Safety, Critical and Normal Branch of the EES. Renovations may change what is served by the circuits providing a pattern of mixed loads within the building this does not comply with NFPA 99-2012, 6.4.2.2.3. A pattern of mixed loads is shown by example locations:
1. Panel SS-1-CR9
2. Panel SS -1-EQL13.
3. Panel LP-CR-CAR(C1)

Based on observation during the survey walk-through, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

The finding is:

While accompanied by the MRC, the surveyor observation determined that critical care patient beds lack electrical receptacles served by normal power as required by NFPA 70 2011 517-19(A).
Locations observed:

1. On 11/01/2017 at 1:05pm Cath Lab patient holding bays
2. On 11/01/2017 at 2:20pm Emergency Dept Trauma rooms (except Trauma #1).

Base on observation the facility failed to provide protected storage for medical gas cylinders. This deficient practice could result in the uncontrolled spread of fire which may affect patients, staff and visitors.

The finding is:

On 11/1/17 at 9:15 AM accompanied by the DF, it was observed that separation from combustibles of more than 5 feet is not provided for the storage of oxygen cylinders (full/empty) within the General Store Room ground floor. NFPA 99, 2012, 11.3.2.3

Based on observation during the survey walk through the facility failed to provide a safe storage environment for the transfilling of liquid oxygen. This deficient practice could affect the facility and personnel while performing the transfilling process.

The finding is:

On 11/1/17 at 8:20 AM accompanied by the DF, it was observed at the second floor oxygen storage room the transfilling of liquid oxygen to portable containers was taking place. The room flooring material consisted of vinyl floor tile not ceramic or concrete as require by NFPA 99, 2012, 11.5.2.3.