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Based upon observation during the survey walk-through, not all structural components are protected to afford the required fire rating. Failure to provide protection can result in premature failure of the structural components during a fire condition.

Findings include:

On 8/1/16 at 2:15pm it was observed while in the company of the DFM that fire proofing was removed from the steel joist in Stair #5 in non-compliance with 19.1.6.2.

Based on observation, it was determined that the facility failed to maintain the closure of corridor doors. This deficient practice could affect patient, staff and visitors if a fire were to occur in this smoke zone and improper door latching allowed smoke from patient rooms or support areas to fill the exit corridor.

Findings include:

On 08/02/16 at 10:10 AM, while in the company of the DS, the X-Ray Suite, First Floor of the West Pavilion, the corridor door to the Radiology Room #6 is being equipped with a plunger-type hardware, which is un-approved hold open device. This does not comply with NFPA 101, Section 19.3.6.3.3.

Based on observation during the survey walk-through, not all penetrations at floor assemblies are constructed or maintained as fire resistive assemblies. Failure to maintain floor assemblies can allow fire/smoke conditions to pass from one floor to another.

Findings include:

A. Duct penetrations through 2 hour fire rated floor assemblies were observed while in the company of the DFM that could not be confirmed to have fire dampers to comply with NFPA 101-2000, 8.2.3.2.4 and NFPA 90A-1999, 3-3.2 at the plane of the floor because access to required dampers was not provided to comply with NFPA 90A 1999, 2-3.4.1. Locations observed include:

1. On 8/2/16 at 9:50am ducts from the Basement Sister's Housekeeping storage room through the floor above.

2. On 8/2/16 at 10:55am ducts from the Basement Kitchen Dry Storage room through the floor above.

3. On 8/2/16 at 11:30am ducts from the Basement Maintenance Shop through the floor above.

B. Pipe penetrations through 2 hour fire rated floor assemblies were observed while in the company of the DFM that were not sealed in accordance with tested design assemblies to afford the required protection to comply with NFPA 101-2000, 19.3.1.1 and 8.2.3.2.4. Locations observed include:

1. On 8/2/16 at 9:50am multiple pipe penetrations from the Basement Sister's Housekeeping Storage room through the floor above.

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.

Findings include:

A. On 8/1/16 at 1:15pm it was observed while in the company of the DFM, that East Pavilion 3rd floor Storage room/roof access at the east end of the corridor, did not have a positive latching corridor door to comply with 19.3.2.1, 8.4.1 and 19.3.6.3.2.

B. On 8/1/16 at 3:25pm it was observed while in the company of the DFM, the East Pavilion 1st floor old ER/PT area, now used as storage, had two doors which were not self-closing to a latched condition. One lacked a closer and hung-up on the floor and the other would not close to engage the latch to comply with 19.3.2.1 and 8.4.1.

C. On 8/1/16 at 3:30pm it was observed while in the company of the DFM, the East Pavilion 1st floor Administration area storage room door, across from the Ambulatory and Ancillary Service office, was not self-closing to comply with 19.3.2.1 and 8.4.1.

D. On 8/2/16 at 9:25am it was observed while in the company of the DFM, the East Pavilion 1st floor Cath Lab Clean Storage room door was not self-closing to a latched condition to comply with 19.3.2.1 and 8.4.1.

E. On 8/2/16 at 9:35am it was observed while in the company of the DFM, the East Pavilion Basement floor Medical Records Storage room single door, near the SE exit to an exterior areaway stair, was not self-closing to comply with 19.3.2.1 and 8.4.1.

F. On 8/2/16 at 9:45am it was observed while in the company of the DFM, typical East Pavilion Basement Storage rooms and Shops with pairs of corridor doors equipped with closers, automatic flush bolts and astragals lacked coordinating hardware to ensure doors will close and latch in the proper sequence to comply with 19.3.2.1, 8.4.1 and 19.3.6.3.2. The Bed Shop door also had a hold-open feature as part of the closer that is not in accordance with 7.2.1.8.

G. On 8/2/16 at 10:55am it was observed while in the company of the DFM, the East Pavilion Basement Kitchen Dry Storage room pair of doors was equipped with manual flush bolts which were not engaged and the door was not closed to a latched condition to comply with 19.3.2.1 and 8.4.1.


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H. On 08/01/16 at 2:25 PM, while in the company of the DS and the RDSS, the surveyor observed on the First Floor of the West Pavilion, OB/Nursery Suite, the Soiled Utility Room T1043, required to be fire separated from other areas, lacked a self-closing door to comply with 19.3.2.1.

I. On 08/01/16 at 9:40 AM, while in the company of the DS and the RDSS, the surveyor observed on the First Floor of the West Pavilion, the Outpatient Pre-OP Room #12 is being used for a storage, which is considered hazardous, lacked a self-closing door to comply with 19.3.2.1.

J. On 08/01/16 at 1:10 PM, while in the company of the DS and the RDSS, the surveyor observed that on the 3rd Floor of the West Pavilion, the Soiled Utility Room W3127, which is required to be separated by fire rated construction, was observed with conduit penetrations that are not fire sealed to comply with 8.2.3.2.4.2 and 19.3.2.1.

Based upon observation during the survey walk-through, Exit access components are not constructed in accordance with requirements. Failure to provide compliant components can compromise occupants ability to utilize such components effectively.

Findings include:

On 8/2/16 at 11:15am while in the company of the DFM it was observed the Basement level ramp, in the corridor that leads to the SE exterior exit door, lacked at least one handrail to comply with 19.2.2.6.1, 7.2.5.4, and 7.2.2.4.2 Exception No. 3.

Based on observation during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. On 8/1/16 at 12:45pm it was observed while in the company of the DFM, the East Pavilion 4th floor Peds unit is provided with magnetic locking systems as part of a HUGS system for the stair exit doors. The system does not have a delayed egress function to comply with NFPA 101-2000, 19.2.2.2.4 Exception No. 2. The installation otherwise does not comply with all requirements of NFPA 101-2012, 19.2.2.2.5.2 which permits locks without delayed egress.

B. On 8/1/16 at 3:20pm it was observed while in the company of the DFM, the East Loading Dock exterior exit door was equipped with a magnetic Access Controlled Egress Door locking system that lacked the manual release device required by NFPA 101-2000, 7.2.1.6.2(c).

C. On 8/1/16 at 3:30pm it was observed while in the company of the DFM, the East Pavilion North stair exterior exit door was equipped with a magnetic Access Controlled Egress Door locking system that lacked the manual release device required by NFPA 101-2000, 7.2.1.6.2(c).

D. On 8/2/16 at 9:35am it was observed while in the company of the DFM, the Basement Medical Records/Gift Shop storage caged areas were provided with keyed-both-sides locks which can prevent exiting from the cage. The locks do not comply with NFPA 101-2000, 7.2.1.5.1 because they require a key to operate from the egress side when locked.

E. On 8/1/16 at 2:00pm it was observed while in the company of the DFM, the East Pavilion 2nd floor south wing only has access to one exit stair which does not comply with NFPA 101-2000, 19.2.4.1. This area is the non-behavioral health portion of the floor. The other two exit stairs for the floor are located within the locked behavioral health unit.

F. On 8/1/16 at 1:00pm it was observed while in the company of the DFM, the East Pavilion 3rd floor Pastoral Care office, housing multiple occupants, had both a latchset and a deadbolt lock on the corridor door. This arrangement does not comply with NFPA 101-2000, 7.2.1.5.4 because the door does not operate with only one releasing operation when the lock is engaged.

Based upon document review, staff interview and observation during the survey walk-thru, the size of designated suites does not comply with the Code limitations. Failure to limit the size of suites to that permitted can result in the inability of occupants to move effectively to an area of safety.

Findings include:

On 8/1/16 at 11:00am the Provider indicated that the OR suite is a 10,200 sf non-sleeping suite. There are no provisions for a non-sleeping suite to be greater than 10,000 sf and remain in compliance with NFPA 101-2000, 19.2.5.7 or NFPA 101-2012, 19.2.5.7.3.3.

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.

Findings include:

A. Exit signs are not provided to identify the means of egress from aisles/corridors to comply with 19.2.5.9, 19.2.10.1 and 7.10.

Locations observed include the following:

1. On 8/2/16 at 9:45am it was observed while in the company of the DFM, the East Pavilion Basement Corridor leading to the SE exit door identified only a single path of exit to the SE exit door. The double egress cross corridor doors lacked exit signage to identify them as the second available exit to comply with 19.2.5.9, 19.2.10 and 7.10.

2. On 8/2/16 at 9:20am it was observed while in the company of the DFM, the East Pavilion 1st floor corridor leading north and then east from the elevators was directed through a single leaf door which did not swing in the direction of egress travel to comply with 7.2.1.4.2. This section of corridor would otherwise be a compliant dead end in accordance with 18/19.2.5.10 if exit signage did not direct occupants through this door.


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3. On 08/02/16 at 9:25 AM, while in the company of the DS, the surveyor observed on the First Floor of the West Pavilion, the Surgery Suite aisle by the OR#2 and OR#3, exit signs are not provided to define the available path of egress to an exit. This does not comply with 19.2.10.1.

4. On 08/02/16 at 10:30 AM, while in the company of the DS, the surveyor observed on the Lower Level of the West Pavilion, the exit access corridor, by the Janitor's Closet 0239, and near the Stairwell #8, lacked exit signs to identify access to two available exits. This does not comply with 19.2.5.9, 19.2.10.1.

5. On 08/02/16 at 10:45 AM, while in the company of the DS, the surveyor observed on the Lower Level of the West Pavilion, Sterile Processing Department (SPD) with 7,520 sq. ft, which path of egress travel is not obvious, the required exit signs leading to exits are not installed. This does not comply with 19.2.10.1.

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with Code requirements. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

A. On 08/02/16, at 2:30 PM, while in the company of the DS, the surveyor observed that on the First Floor of the West Pavilion, OB / Nursery Suite, smoke detectors are installed within 3'-0" of the supply air / exhaust diffusers. This does not comply with NFPA 72 1999 2-3.5.1.

Locations include:

1. OB Suite - Patient Room W107
2. Nurses Station Area T1046


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Based on observation during the survey walk through the fire alarm sub panels were not properly protected. This could affect all occupants of the building if the fire alarm system did not operate properly during a fire emergency.

Findings include:

B. On 8/3/16 at 10:45 am, while accompanied by the DF and the MT, the surveyor observed that Room E510 was an unoccupied closet and did not have a smoke detector near the fire alarm panel to meet the requirements of NFPA-72, Section 1-5.6.

Based upon survey walk-through direct observation, sprinkler systems are not installed in accordance with requirements in all areas to consider the facility fully sprinklered. Failure to provide full sprinkler coverage can result in areas being unprotected from the spread of fire conditions.

Findings include:

A. On 8/1/16 at 12:15pm it was observed while in the company of the DFM, the East Pavilion elevator machine room space was not provided with sprinkler protection in accordance with NFPA 13-1999, 5-1.1.

B. On 8/1/16 at 12:30pm it was observed while in the company of the DFM, the East Pavilion 5th floor Janitor closet E5104 contained sprinkler system piping and valves which were not labeled to comply with NFPA 13-1999, 3-8.3.

C. On 8/2/16 at 11:00am it was observed while in the company of the DFM, the East Pavilion basement kitchen dry storage room sprinkler heads were not installed within 12" of the flat ceiling surface to comply with NFPA 13-1999, 5-6.4.1.1.

D. On 8/2/16 at 11:15am it was observed while in the company of the DFM, the East Pavilion basement kitchen compressor room sprinkler coverage was compromised by the open ceiling system around the light fixture. Openings in the ceiling could prevent proper activation of the sprinkler head in accordance with NFPA 13-1999, 5-6.4.1.1.


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E. On 08/01/16 at 12:40 PM, while in the company of the DS and the RDSS, the surveyor observed that the West Pavilion Elevator Penthouse Machine Room lacked sprinkler protection.

Based on observation the facility failed to maintain automatic sprinkler protection. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

A. On 08/01/16 at 1:10 PM, while in the company of the DS and the RDSS, the surveyor observed on the Third Floor of the West Pavilion, the sprinkler heads are covered with dust and lint. This does not comply with NFPA 25 1998 2-2.1.1.

Locations include:

1. Patient Room W307
2. Patient Toilet Room W309

B. On 08/01/16 at 1:15 PM, while in the company of the DS and the RDSS, the surveyor
observed on the Third Floor of the West Pavilion, that the sprinkler heads are painted, which does not comply with NFPA 25 1998 2-2.1.1.

Locations include:

1. Third Floor Patient Toilet Room W 309
2. First Floor ED skylight

Based on direct observation during the survey walk-through, the facility failed to provide compliant installation of appliances under the grease capture hoods in the dietary department. Improper installation can result in spread of flame and products of combustion.

Findings include:

A. On 8/2/16 at 9:30 am, while in the company of the DF, the deep fat fryers in the main kitchen and cafeteria are installed adjacent to and not separated by 16 inches from the open flame range top as required by NFPA 96, 1998, 9-1.2.3.

B. On 8/2/16 at 9:30 am, while in the company of the DF, the grease filters are installed with openings between segments allowing grease laden vapors to bypass the capture devices. NFPA 96, 1998, 3-2.3

Based on observation during the survey walk-through, not all medical gas piping systems are installed and maintained in accordance with Code requirements. This deficiency could affect any patients in the cited area because the medical gas system could become compromised.

Findings include:

On 08/02/16, at 9:20 AM, while in the company of the DS, the surveyor observed on the First Floor of the West Pavilion, the medical gas zone (shut-off) valves serving Patient Holding T1193- 1, 3, 5, 4 and the Outpatient Recovery Bays were observed to be located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d).

Based upon observations during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other Code requirements that are not documented under other K-Tags.

Findings include:

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 (ILSM) 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 ILSM to remain in place as work toward the completion of its PoC progresses.

Based on observation, the emergency power was not properly divided into three branches. This could effect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/2/16 at 10:30 am, while accompanied by the DF and the MT, the surveyor observed that critical panel CR-5 was serving a fire alarm panel that should be served from the life safety branch of emergency power. This was not in compliance with the 1999 Edition of NFPA-70, Sections 517-32 and 517-33. All such fire alarm panels should be confirmed to be on Life Safety panels rather than Critical branch panels.

Based upon survey walk-through direct observation, electrical systems are not installed in accordance with requirements in all areas. Failure to provide proper electrical installations can result in electrical shock hazards to occupants.

Findings include:

A. On 8/1/16 at 12:30pm while in the company of the DFM it was observed that an outlet adjacent the sink in the East Pavilion 4th floor Peds Physical Therapy room identified as being fed from Panel 4B circuit 29 was not GFCI protected to comply with NFPA 70-1999, 210-8(b).


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Based on observation, the facility failed to provide a proper electrical system. This could effect any patient if a transfer switch failed.

Findings include:

B. On 8/2/16 between 10:30 and 11:30 am, while accompanied by the DF and the MT, the surveyor observed the following areas were not equipped with normal power receptacles or receptacles served from two separate critical transfer switches as required by the 1999 Edition of NFPA-99, Section 3-3.2.1.2(a)1.

1. The operating rooms
2. The recovery rooms
3. The Emergency Rooms

C. On 8/2/16 at 11:15 am, while accompanied by the DF and the MT, the surveyor observed that the west tower elevator equipment room was not equipped with a lighting disconnect served from the life safety branch of emergency power in accordance with the 1999 Edition of NFPA-70, Section 620-22, and Section 517-32.

Based upon observation during the survey walk-through, not all structural components are protected to afford the required fire rating. Failure to provide protection can result in premature failure of the structural components during a fire condition.

Findings include:

On 8/1/16 at 2:15pm it was observed while in the company of the DFM that fire proofing was removed from the steel joist in Stair #5 in non-compliance with 19.1.6.2.

Based on observation, it was determined that the facility failed to maintain the closure of corridor doors. This deficient practice could affect patient, staff and visitors if a fire were to occur in this smoke zone and improper door latching allowed smoke from patient rooms or support areas to fill the exit corridor.

Findings include:

On 08/02/16 at 10:10 AM, while in the company of the DS, the X-Ray Suite, First Floor of the West Pavilion, the corridor door to the Radiology Room #6 is being equipped with a plunger-type hardware, which is un-approved hold open device. This does not comply with NFPA 101, Section 19.3.6.3.3.

Based on observation during the survey walk-through, not all penetrations at floor assemblies are constructed or maintained as fire resistive assemblies. Failure to maintain floor assemblies can allow fire/smoke conditions to pass from one floor to another.

Findings include:

A. Duct penetrations through 2 hour fire rated floor assemblies were observed while in the company of the DFM that could not be confirmed to have fire dampers to comply with NFPA 101-2000, 8.2.3.2.4 and NFPA 90A-1999, 3-3.2 at the plane of the floor because access to required dampers was not provided to comply with NFPA 90A 1999, 2-3.4.1. Locations observed include:

1. On 8/2/16 at 9:50am ducts from the Basement Sister's Housekeeping storage room through the floor above.

2. On 8/2/16 at 10:55am ducts from the Basement Kitchen Dry Storage room through the floor above.

3. On 8/2/16 at 11:30am ducts from the Basement Maintenance Shop through the floor above.

B. Pipe penetrations through 2 hour fire rated floor assemblies were observed while in the company of the DFM that were not sealed in accordance with tested design assemblies to afford the required protection to comply with NFPA 101-2000, 19.3.1.1 and 8.2.3.2.4. Locations observed include:

1. On 8/2/16 at 9:50am multiple pipe penetrations from the Basement Sister's Housekeeping Storage room through the floor above.

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.

Findings include:

A. On 8/1/16 at 1:15pm it was observed while in the company of the DFM, that East Pavilion 3rd floor Storage room/roof access at the east end of the corridor, did not have a positive latching corridor door to comply with 19.3.2.1, 8.4.1 and 19.3.6.3.2.

B. On 8/1/16 at 3:25pm it was observed while in the company of the DFM, the East Pavilion 1st floor old ER/PT area, now used as storage, had two doors which were not self-closing to a latched condition. One lacked a closer and hung-up on the floor and the other would not close to engage the latch to comply with 19.3.2.1 and 8.4.1.

C. On 8/1/16 at 3:30pm it was observed while in the company of the DFM, the East Pavilion 1st floor Administration area storage room door, across from the Ambulatory and Ancillary Service office, was not self-closing to comply with 19.3.2.1 and 8.4.1.

D. On 8/2/16 at 9:25am it was observed while in the company of the DFM, the East Pavilion 1st floor Cath Lab Clean Storage room door was not self-closing to a latched condition to comply with 19.3.2.1 and 8.4.1.

E. On 8/2/16 at 9:35am it was observed while in the company of the DFM, the East Pavilion Basement floor Medical Records Storage room single door, near the SE exit to an exterior areaway stair, was not self-closing to comply with 19.3.2.1 and 8.4.1.

F. On 8/2/16 at 9:45am it was observed while in the company of the DFM, typical East Pavilion Basement Storage rooms and Shops with pairs of corridor doors equipped with closers, automatic flush bolts and astragals lacked coordinating hardware to ensure doors will close and latch in the proper sequence to comply with 19.3.2.1, 8.4.1 and 19.3.6.3.2. The Bed Shop door also had a hold-open feature as part of the closer that is not in accordance with 7.2.1.8.

G. On 8/2/16 at 10:55am it was observed while in the company of the DFM, the East Pavilion Basement Kitchen Dry Storage room pair of doors was equipped with manual flush bolts which were not engaged and the door was not closed to a latched condition to comply with 19.3.2.1 and 8.4.1.


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H. On 08/01/16 at 2:25 PM, while in the company of the DS and the RDSS, the surveyor observed on the First Floor of the West Pavilion, OB/Nursery Suite, the Soiled Utility Room T1043, required to be fire separated from other areas, lacked a self-closing door to comply with 19.3.2.1.

I. On 08/01/16 at 9:40 AM, while in the company of the DS and the RDSS, the surveyor observed on the First Floor of the West Pavilion, the Outpatient Pre-OP Room #12 is being used for a storage, which is considered hazardous, lacked a self-closing door to comply with 19.3.2.1.

J. On 08/01/16 at 1:10 PM, while in the company of the DS and the RDSS, the surveyor observed that on the 3rd Floor of the West Pavilion, the Soiled Utility Room W3127, which is required to be separated by fire rated construction, was observed with conduit penetrations that are not fire sealed to comply with 8.2.3.2.4.2 and 19.3.2.1.

Based upon observation during the survey walk-through, Exit access components are not constructed in accordance with requirements. Failure to provide compliant components can compromise occupants ability to utilize such components effectively.

Findings include:

On 8/2/16 at 11:15am while in the company of the DFM it was observed the Basement level ramp, in the corridor that leads to the SE exterior exit door, lacked at least one handrail to comply with 19.2.2.6.1, 7.2.5.4, and 7.2.2.4.2 Exception No. 3.

Based on observation during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. On 8/1/16 at 12:45pm it was observed while in the company of the DFM, the East Pavilion 4th floor Peds unit is provided with magnetic locking systems as part of a HUGS system for the stair exit doors. The system does not have a delayed egress function to comply with NFPA 101-2000, 19.2.2.2.4 Exception No. 2. The installation otherwise does not comply with all requirements of NFPA 101-2012, 19.2.2.2.5.2 which permits locks without delayed egress.

B. On 8/1/16 at 3:20pm it was observed while in the company of the DFM, the East Loading Dock exterior exit door was equipped with a magnetic Access Controlled Egress Door locking system that lacked the manual release device required by NFPA 101-2000, 7.2.1.6.2(c).

C. On 8/1/16 at 3:30pm it was observed while in the company of the DFM, the East Pavilion North stair exterior exit door was equipped with a magnetic Access Controlled Egress Door locking system that lacked the manual release device required by NFPA 101-2000, 7.2.1.6.2(c).

D. On 8/2/16 at 9:35am it was observed while in the company of the DFM, the Basement Medical Records/Gift Shop storage caged areas were provided with keyed-both-sides locks which can prevent exiting from the cage. The locks do not comply with NFPA 101-2000, 7.2.1.5.1 because they require a key to operate from the egress side when locked.

E. On 8/1/16 at 2:00pm it was observed while in the company of the DFM, the East Pavilion 2nd floor south wing only has access to one exit stair which does not comply with NFPA 101-2000, 19.2.4.1. This area is the non-behavioral health portion of the floor. The other two exit stairs for the floor are located within the locked behavioral health unit.

F. On 8/1/16 at 1:00pm it was observed while in the company of the DFM, the East Pavilion 3rd floor Pastoral Care office, housing multiple occupants, had both a latchset and a deadbolt lock on the corridor door. This arrangement does not comply with NFPA 101-2000, 7.2.1.5.4 because the door does not operate with only one releasing operation when the lock is engaged.

Based upon document review, staff interview and observation during the survey walk-thru, the size of designated suites does not comply with the Code limitations. Failure to limit the size of suites to that permitted can result in the inability of occupants to move effectively to an area of safety.

Findings include:

On 8/1/16 at 11:00am the Provider indicated that the OR suite is a 10,200 sf non-sleeping suite. There are no provisions for a non-sleeping suite to be greater than 10,000 sf and remain in compliance with NFPA 101-2000, 19.2.5.7 or NFPA 101-2012, 19.2.5.7.3.3.

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.

Findings include:

A. Exit signs are not provided to identify the means of egress from aisles/corridors to comply with 19.2.5.9, 19.2.10.1 and 7.10.

Locations observed include the following:

1. On 8/2/16 at 9:45am it was observed while in the company of the DFM, the East Pavilion Basement Corridor leading to the SE exit door identified only a single path of exit to the SE exit door. The double egress cross corridor doors lacked exit signage to identify them as the second available exit to comply with 19.2.5.9, 19.2.10 and 7.10.

2. On 8/2/16 at 9:20am it was observed while in the company of the DFM, the East Pavilion 1st floor corridor leading north and then east from the elevators was directed through a single leaf door which did not swing in the direction of egress travel to comply with 7.2.1.4.2. This section of corridor would otherwise be a compliant dead end in accordance with 18/19.2.5.10 if exit signage did not direct occupants through this door.


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3. On 08/02/16 at 9:25 AM, while in the company of the DS, the surveyor observed on the First Floor of the West Pavilion, the Surgery Suite aisle by the OR#2 and OR#3, exit signs are not provided to define the available path of egress to an exit. This does not comply with 19.2.10.1.

4. On 08/02/16 at 10:30 AM, while in the company of the DS, the surveyor observed on the Lower Level of the West Pavilion, the exit access corridor, by the Janitor's Closet 0239, and near the Stairwell #8, lacked exit signs to identify access to two available exits. This does not comply with 19.2.5.9, 19.2.10.1.

5. On 08/02/16 at 10:45 AM, while in the company of the DS, the surveyor observed on the Lower Level of the West Pavilion, Sterile Processing Department (SPD) with 7,520 sq. ft, which path of egress travel is not obvious, the required exit signs leading to exits are not installed. This does not comply with 19.2.10.1.

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with Code requirements. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

A. On 08/02/16, at 2:30 PM, while in the company of the DS, the surveyor observed that on the First Floor of the West Pavilion, OB / Nursery Suite, smoke detectors are installed within 3'-0" of the supply air / exhaust diffusers. This does not comply with NFPA 72 1999 2-3.5.1.

Locations include:

1. OB Suite - Patient Room W107
2. Nurses Station Area T1046


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Based on observation during the survey walk through the fire alarm sub panels were not properly protected. This could affect all occupants of the building if the fire alarm system did not operate properly during a fire emergency.

Findings include:

B. On 8/3/16 at 10:45 am, while accompanied by the DF and the MT, the surveyor observed that Room E510 was an unoccupied closet and did not have a smoke detector near the fire alarm panel to meet the requirements of NFPA-72, Section 1-5.6.

Based upon survey walk-through direct observation, sprinkler systems are not installed in accordance with requirements in all areas to consider the facility fully sprinklered. Failure to provide full sprinkler coverage can result in areas being unprotected from the spread of fire conditions.

Findings include:

A. On 8/1/16 at 12:15pm it was observed while in the company of the DFM, the East Pavilion elevator machine room space was not provided with sprinkler protection in accordance with NFPA 13-1999, 5-1.1.

B. On 8/1/16 at 12:30pm it was observed while in the company of the DFM, the East Pavilion 5th floor Janitor closet E5104 contained sprinkler system piping and valves which were not labeled to comply with NFPA 13-1999, 3-8.3.

C. On 8/2/16 at 11:00am it was observed while in the company of the DFM, the East Pavilion basement kitchen dry storage room sprinkler heads were not installed within 12" of the flat ceiling surface to comply with NFPA 13-1999, 5-6.4.1.1.

D. On 8/2/16 at 11:15am it was observed while in the company of the DFM, the East Pavilion basement kitchen compressor room sprinkler coverage was compromised by the open ceiling system around the light fixture. Openings in the ceiling could prevent proper activation of the sprinkler head in accordance with NFPA 13-1999, 5-6.4.1.1.


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E. On 08/01/16 at 12:40 PM, while in the company of the DS and the RDSS, the surveyor observed that the West Pavilion Elevator Penthouse Machine Room lacked sprinkler protection.

Based on observation the facility failed to maintain automatic sprinkler protection. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

A. On 08/01/16 at 1:10 PM, while in the company of the DS and the RDSS, the surveyor observed on the Third Floor of the West Pavilion, the sprinkler heads are covered with dust and lint. This does not comply with NFPA 25 1998 2-2.1.1.

Locations include:

1. Patient Room W307
2. Patient Toilet Room W309

B. On 08/01/16 at 1:15 PM, while in the company of the DS and the RDSS, the surveyor
observed on the Third Floor of the West Pavilion, that the sprinkler heads are painted, which does not comply with NFPA 25 1998 2-2.1.1.

Locations include:

1. Third Floor Patient Toilet Room W 309
2. First Floor ED skylight

Based on direct observation during the survey walk-through, the facility failed to provide compliant installation of appliances under the grease capture hoods in the dietary department. Improper installation can result in spread of flame and products of combustion.

Findings include:

A. On 8/2/16 at 9:30 am, while in the company of the DF, the deep fat fryers in the main kitchen and cafeteria are installed adjacent to and not separated by 16 inches from the open flame range top as required by NFPA 96, 1998, 9-1.2.3.

B. On 8/2/16 at 9:30 am, while in the company of the DF, the grease filters are installed with openings between segments allowing grease laden vapors to bypass the capture devices. NFPA 96, 1998, 3-2.3

Based on observation during the survey walk-through, not all medical gas piping systems are installed and maintained in accordance with Code requirements. This deficiency could affect any patients in the cited area because the medical gas system could become compromised.

Findings include:

On 08/02/16, at 9:20 AM, while in the company of the DS, the surveyor observed on the First Floor of the West Pavilion, the medical gas zone (shut-off) valves serving Patient Holding T1193- 1, 3, 5, 4 and the Outpatient Recovery Bays were observed to be located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d).

Based upon observations during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other Code requirements that are not documented under other K-Tags.

Findings include:

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 (ILSM) 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 ILSM to remain in place as work toward the completion of its PoC progresses.

Based on observation, the emergency power was not properly divided into three branches. This could effect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/2/16 at 10:30 am, while accompanied by the DF and the MT, the surveyor observed that critical panel CR-5 was serving a fire alarm panel that should be served from the life safety branch of emergency power. This was not in compliance with the 1999 Edition of NFPA-70, Sections 517-32 and 517-33. All such fire alarm panels should be confirmed to be on Life Safety panels rather than Critical branch panels.

Based upon survey walk-through direct observation, electrical systems are not installed in accordance with requirements in all areas. Failure to provide proper electrical installations can result in electrical shock hazards to occupants.

Findings include:

A. On 8/1/16 at 12:30pm while in the company of the DFM it was observed that an outlet adjacent the sink in the East Pavilion 4th floor Peds Physical Therapy room identified as being fed from Panel 4B circuit 29 was not GFCI protected to comply with NFPA 70-1999, 210-8(b).


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Based on observation, the facility failed to provide a proper electrical system. This could effect any patient if a transfer switch failed.

Findings include:

B. On 8/2/16 between 10:30 and 11:30 am, while accompanied by the DF and the MT, the surveyor observed the following areas were not equipped with normal power receptacles or receptacles served from two separate critical transfer switches as required by the 1999 Edition of NFPA-99, Section 3-3.2.1.2(a)1.

1. The operating rooms
2. The recovery rooms
3. The Emergency Rooms

C. On 8/2/16 at 11:15 am, while accompanied by the DF and the MT, the surveyor observed that the west tower elevator equipment room was not equipped with a lighting disconnect served from the life safety branch of emergency power in accordance with the 1999 Edition of NFPA-70, Section 620-22, and Section 517-32.