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Based upon observation, the required building separations are not maintained to afford the designated hourly rated barriers. Failure to maintain building separations can permit fire/smoke conditions to pass from one building to another in the event of a fire emergency.

Findings include:

On 07/30/18 at 1:45 PM while in the company of the FOM, it was observed that the magnetically held-open 4-hour barrier single swing doors at the Lower Concourse level between the Feinburg building and the tunnel to the Lavin building lacked a coordinator to permit the doors to close and latch to comply with 19.1.3.4.1 and NFPA 80-2010, 6.1.4 when one door is opened after both doors are initially closed.

Based on observation, 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 07/30/18, while accompanied by the SFM, it was observed that support beams lack spray fire proofing. This does not comply with Table 19.1.6.1 and NFPA 220 2012 Ed. Table 4.1.1.

Locations include:

A. At 2:05 PM, the beam by the Stair Exit access of the Chiller Room (17th Floor).

B. At 11:30 AM, the structural beam in the 17th Floor of the Boiler Room.

C. At 2:40 PM, structural beam by the Catwalk Mezzanine (Mechanical Room).

Based on observation, means of egress are not maintained clear of obstructions. Failure to maintain means of egress clear of obstructions can prevent occupants from reaching an exit in the event of a fire/smoke emergency.

Findings include:

A. On 07/31/18 at 9:30 AM while in the company of the FOM, it was observed that housekeeping containers exceeding 32 gal. capacity were stationed in the 4-hour Vestibule L-233A near Office L-328A in noncompliance with 19.2.1 and 7.1.10.1.

B. On 07/31/18 at 11:30 AM while in the company of the FOM, it was observed that furniture in Lounge 1-713 of the Staff Lockers suite obstructed the use of the corridor exit door. This door was also not easily latched to comply with 19.3.6.3.5.

C. On 08/01/18 at 1:30 PM while in the company of the FOM, it was observed that a janitor cart was stationed in the 6th floor exit access "tunnel" corridor leading to Stair D entrance in noncompliance with 19.2.1 and 7.1.10.1.

Based on observation and interview, the facility failed to maintain Egress Doors. This deficient practice could affect patients, staff and visitors if the egress doors did not function properly during an emergency. Failure to install locking devices in accordance with requirements can prevent or cause undue delay in exiting or evacuation procedures when required.

Findings include:

A. While in the company of the FOM, it was observed that locking systems which prevent egress from occupied spaces are not in compliance with 19.2.2.2.4 and 7.2.1.5.3. Chain & padlocks were used in noncompliance with 7.2.1.5.3. These locks were in addition to the gate latch lock. The provisions for two locks on a means of egress door does not comply with 19.2.2.2.6(2) and 7.2.1.5.10.2.

Locations include:

1. On 07/30/18 at 2:15 PM - L-727 Vac Lock-up (Tina's cage)
2. On 07/30/18 at 2:20 PM - L-718 cage
3. On 07/31/18 at 9:45 AM - L-516 Vending cage at Food Storage room

B. While in the company of the FOM, it was observed that locking systems which employ magnetic locking devices were installed on egress doors which were not in full compliance with 19.2.2.2.4. Per interview, the locking systems are normally inactive during the business day and are actively locked after 4 PM by the security system. The provisions of 7.2.1.6.1.1(4) Delayed Egress locks were not met due to the lack of signage indicating the 15 second delay. The provisions of 7.2.1.6.2(1) Access Controlled Egress were not met due to the lack of sensors to unlock the magnets. Doors observed to lack full compliance with the requirements include the following locations:

1. On 07/30/18 at 3:05 PM - The outer cross corridor doors at corridor L-704 leading to Pharmacy, lack signage for Delayed Egress or sensors for Access Controlled Egress. Manual operation of the doors exceeds the 15 lbf force permitted by 7.2.1.4.5 to open the doors.

2. On 07/31/18 at 9:35 AM - The Materials Management L-323 doors have a sensor for Access Controlled Egress but always requires wall push-button activation to release & open the door(s).

3. On 07/31/18 at 10:35 AM - The ED northwest exit doors lack signage for Delayed Egress or sensors for Access Controlled Egress. The provisions of 19.2.2.2.5.2 are not otherwise met.

4. On 07/31/18 at 12:45 PM - The cross corridor exit doors, east and west, from the Staff Elevators on the Mezzanine level have magnetic locks not signed as Delayed Egress. These doors have sensors but the functional operation of the locks after hours could not be tested to confirmed locking system operation.

5. On 07/31/18 at 2:45 PM - The cross corridor exit doors east of the Staff Elevators on the 3rd floor lacked signage for Delayed Egress or sensors for Access Controlled Egress.

6. On 08/01/18 at 10:55 AM - The 5th floor PACU suite doors (both at the west corridor to Galter & the east doors to Corridor 5-303) lack signage for Delayed Egress or sensors for Access Controlled Egress.

7. On 08/01/18 at 10:58 AM - The 5th floor doors from the restricted corridor of Feinberg to the non-restricted corridors of Galter lack signage for Delayed Egress or sensors for Access Controlled Egress.

C. While in the company of the FOM, it was observed that marked exit access doors have locking systems which prevent egress which does not comply with 19.2.2.2.4.

Locations include:

1. On 07/31/18 at 2:47 PM - The marked exit access door for the 3rd floor corridor T3080, directed thru the Executive Administration reception office area 3-706, is locked from the corridor egress side.

2. On 08/01/18 at 9:30 AM - The marked exit access door from Waiting 4-302 to Corridor 4-303 is locked from the egress side.


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D. On 07/31/18 at 9:00 AM, while accompanied by CPM, it was determined that on the 13th floor, Public Corridor, West Medical Unit, 15-second delayed egress doors when tested, reset automatically. This does not comply with 19.2.2.2.4 and 7.2.1.6.1.1(3)(d).

Based on observation, not all egress doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress under emergency conditions could be impeded if they are not properly installed and maintained.

Findings include:

On 08/01/18 at 9:30 AM, while accompanied by the PMCPO, observation determined that the re-locking of the delayed egress doors from Thirteenth Floor Corridor G13-200 to Corridor T13081, which are equipped with delayed egress locking mechanisms, is not by a manual means as required by 7.2.1.6.1.1(3)(d).

Based on observation, means of egress doors are locked without full compliance with Code allowance provisions. Failure to install locking devices for means of egress doors in full compliance with all requirements can result in building occupants not being able to reach an area of safety or an exit from the building if there is a fire/smoke event.

Findings include:

A. On 07/31/18 while accompanied by SFM, it was observed that designated egress doors equipped with magnetic locking devices other than Delayed Egress locking systems are not compliant with 19.2.2.2.4. Per interview the locking systems are normally inactive during the business day and actively locked at night by a security system. These doors when locked do not comply with all the delayed egress requirements of 7.2.1.6 or the provisions of 19.2.2.2.5.2.

Locations include:

1. At 2:00 AM, 17th Floor of the Stem Cell Unit from the Public Elevator Lobby.

2. At 9:45 AM, 16th Floor of the Stem Cell Unit from the Public Elevator Lobby.


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B. On 08/01/2018 while in the company of the SFM, it was observed that the delayed egress locking devices installed at the cross corridor doors and exit Stairs automatically reset after phasing through a cycle. This does not comply with 7.2.1.6.1.1 (3.d.).

Locations include:

1. At 10:20 AM, 2nd floor adjacent to Stair C and Security.

2. At 1:20 PM 6th floor adjacent to Stair C and Trash Chute room.

3. At 9:45 AM Lower Level adjacent to Office # 2312 within tunnel #T0003.

4. At 2:20 PM 8th floor adjacent to Stair A.

Based on observation, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor during a fire emergency.

Findings include:

On 07/30/2018 at 9:50 AM while accompanied by the SFM, a pair of entry doors were observed having a manual flush bolt which was not engaged. Upon closing the doors, the surveyor was able to push on one door which opened both. Upon closing the doors again, they did not latch in order to comply with 19.3.2.1 and 8.4.1.

Locations include:

1. Lower Level floor - pair of corridor entry doors at Mail Center (#2322).

2. Lower Level floor - pair of corridor entry doors at Materials Management.

Based on observation, not all stairways are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, the ability to exit the building under emergency conditions could be compromised if the stairways are not properly constructed and maintained.

Finding include:

A. On 07/31/18 at 9:15 AM while accompanied by the ACE, observation determined that Fourth Floor Exit Corridor T0472 is being used for storing large quantities of combustible material ranging from trash, cardboard boxes, and a trash trolley, blocking the egress path in a manner prohibited by 7.1.3.2.3.


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B. On 07/30/18 at 2:43 PM while accompanied by the PMCPO, the First Floor Northwest Exit Passageway was observed to house paint cans, scaffolds, and other equipment as prohibited by 7.1.3.2.3.

C. On 07/30/18, at 3:09 PM while accompanied by the PMCPO, the First Floor Northwest Exit Passageway was observed to contain the following items or functions, causing the Exit Passageway to serve an alternate purpose as prohibited by 7.1.3.2.3:
1. A security desk.

2. A waiting area.

Based on observation, not all designated exit fire barriers are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because fire barriers are not properly constructed.

Findings include:

On 07/31/18, while accompanied by the PMCPO, observation determined that doors in designated 2 hour fire barriers exist at which the fire resistance rating label is not maintained and legible, as required by 8.3.3.2.3 and NFPA 80 2010 4.3.1, the labels have been painted over.

Locations include:

A. At 1:29 PM Door to Fourth Floor Exit Stair A.

B. At 1:33 PM Door to Fourth Floor Exit Stair B.

Based on observation, not all stair components used within an exit stair are constructed to maintain compliant means of egress to an exit discharge. These deficiencies could affect any patients, staff, or visitors by preventing them from evacuating the building under fire conditions.

Findings include:

On 07/31/18 at 3:00 PM while accompanied by the SFM, the self closing door to Stair "B' on the 16th Floor did not close to a latched position which does not comply with Table 8.3.4.2 and 8.3.3.3.

Based on observation, fire barrier doors are not maintained to provide separation of building areas. Failure to provide required separations can contribute to the spread of fire & smoke beyond the compartment of fire origin and compromise the safety of building occupants in adjacent compartments.

Findings include:

A. While in the company of the FOM, it was observed that the fire barrier doors did not self-close to a latched condition to comply with 8.3.3, 8.3.4 and NFPA 80-2010, 6.1.4.

Locations include:

1. On 07/31/18 at 8:45 AM, the 2-hour barrier cross corridor doors near EVS L-500 did not self-close to a latched condition.

2. On 07/31/18 at 9:30 AM, the power operated doors in the 4-hour barrier between Feinberg & Galter Pavilions near L-306 did not self-close to a latched condition.

3. On 07/31/18 at 9:32 AM, the 4-hour barrier pair of doors near L-323A did not self-close to a latched condition.

4. On 07/31/18 at 9:35 AM, the single door in the 4-hour barrier near L-328A did not self-close to a latched condition.

5. On 8/1/18 at 11:00 AM the 5th floor cross corridor doors in the 2-hour fire/smoke barrier at the SW corner of the restricted surgery corridor did not self-close to a latched condition due to friction between door leaves.


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B. On 8/1/18 at 9:37 AM, while accompanied by CPM it was determined that on the 8th floor, East Unit, 2-hour rated double doors contained deficient door hardware and the north door leaf was damaged. This does not comply with 19.2.5.7.1.2. and NFPA 80, 5.1.5.1.

C. On 8/1/18 at 9:43 AM, while accompanied by CPM it was determined that on the 8th floor, East Unit, 2-hour rated double doors adjacent to room 8-825 contained a gap between the door edges that exceeded the 1/8" minimum requirement. This does not comply with NFPA 80, 6.3.1.7.1.

Based on observation, not all building stories or fire compartments are provided with at least two remote exits. This deficient practice could affect patients, staff, and visitors in the building because they could be prevented from exiting the building under emergency conditions if an insufficient number of exits is provided.

Findings include:

On 07/31/18, while accompanied by the PMCPO, observation determined that building stories exist at which the required exits are not remote from each other, in accordance with 7.5.1.3.1, as required by 19.2.4.2.

Locations include:

A. 1:28 PM: Fourth Floor.

B. 1:30 PM: Third Floor.

C. 1:40 PM: Second Floor.

Based on observation, dead end corridors exist in excess of Code permitted lengths. Failure to restrict egress movements in corridors without access to exits can prevent occupants from reaching an exit or place of refuge during a fire/smoke event.

Findings include:

On 08/01/18 at 1:37 PM while in the company of the FOM, it was observed that corridor 6-109 leading to Mechanical room 6-518 has a dead end condition in excess of 50' in noncompliance with 19.2.5.2.

Based on observation, not all corridors have at least two means of egress identified. Failure to identify required alternate exit paths can prevent occupants from reaching an available exit during an emergency.

Findings include:

A. On 07/30/18 at 1:47 PM while in the company of the FOM, it was observed that corridor L-734F leading from the tunnel from the Lavin building lacked an identified 2nd means of egress to comply with 19.2.5.4, 7.4.1.1 and 7.5.1.1.1.

B. On 07/30/18 at 2:20 PM while in the company of the FOM, it was observed that the corridor serving L-178 lacked an identified 2nd means of egress to comply with 19.2.5.4, 7.4.1.1 and 7.5.1.1.1.

C. On 07/31/18 at 2:48 PM while in the company of the FOM, it was observed that exit access corridor 3-717, serving the Administration Offices and Banquet Hall 3-514, lacked an identified 2nd means of egress to comply with 19.2.5.4, 7.4.1.1 and 7.5.1.1.1.

D. On 07/31/18 at 3:10 PM while in the company of the FOM, it was observed that the exit access corridor 3-207A, serving the Hospital Operators Service 3-210 & General Office 3-143, lacked an identified 2nd means of egress to comply with 19.2.5.4, 7.4.1.1 and 7.5.1.1.1.

E. On 08/01/18 at 10:00 AM while in the company of the FOM, it was observed that exit signage, at the corridor intersection near 4-727 looking north, was not provided to comply with 19.2.5.4, 7.4.1.1 and 7.5.1.1.1.

F. On 08/01/18 at 10:01 AM while in the company of the FOM, it was observed that exit signage, at the corridor intersection near IR #6 looking east, was not provided to comply with 19.2.5.4, 7.4.1.1 and 7.5.1.1.1.

Based on observation, designated suites lack compliant number of exits. This deficiency could affect any staff, patients and visitors from exiting those areas in a timely manner under emergency conditions.

Findings include:

On 07/31/2018 at 11:20 AM while accompanied by the SFM, due to surrounding construction, the 5th floor MRI suite, a non-sleeping patient care suite of approximately 4,000 s.f., contained one means of egress to an exit. This condition does not comply with 19.2.5.5.2, 19.2.5.7.3.2 (A) and (C) due to the following:

1. The second means of egress is through a pair of cross corridor doors which are completely covered with white visqueen and tape. The surveyor questioned staff about emergency exiting, they were not aware of the Facility's Interim Life Safety Measures which included tearing off the taped visqueen and passing through the doors. This does not comply with 7.2.1.1.2 for an obvious, direct path of egress.

2. The temporary exit sign taped on the visqueen covered doors does not comply with 7.10.3 for legibility.

3. The second means of egress out of the suite was through a construction zone which does not comply with 19.3.2.

Based on observation, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

A. On 07/31/18, at 9:09 AM while accompanied by the ACE, observation determined that directional exit signs are not installed at Fourth Floor Exit Corridor T4072 south end as required by 7.10.3.1.


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B. On 07/31/18, while accompanied by the PMCPO, observation determined that signs exist which read "STAIR" and not "EXIT" as required by 7.10.3.1.

Locations include:

1. At 8:57 AM: Mezzanine landing, Exit Stair 4.

2. At 9:07 AM: Mezzanine landing, Exit Stair 3.

Based on observation, exit signs are not maintained to define access to at least two means of egress from a floor level to comply with Code requirements. Failure to define access to exits can prevent occupants from reaching an alternate exit when the primary exit access is compromised.

Findings include:

A. On 08/01/18 at 9:40 AM while in the company of the FOM, it was observed that the exit sign, at the east side of the cross corridor doors between corridor 4-303 & the corridor to the east, was obstructed by other signage in noncompliance with 7.10.1.8.

B. On 08/01/18 at 10:01 AM while in the company of the FOM, it was observed that the exit sign, in corridor 4-763A looking north, was obstructed by other signage in noncompliance with 7.10.1.8.

C. On 08/01/18 at 11:15 AM while in the company of the FOM, it was observed that an exit sign was not visible from the east OR corridor leading toward the Pathology suite area cross corridor doors to comply with 7.10.2.1.

Based on observation, exit signs are not provided to define access to at least two means of egress from a floor level to comply with Code requirements. Failure to define exits can prevent occupants from reaching an alternate exit when the primary exit access is compromised during an emergency event.

Findings include:

A. On 08/02/18 at 9:15 AM while in the company of the FOM, it was observed that the cross corridor doors north of the employee elevator lobby lacked exit signage to direct occupants to the available 2nd exit from this portion of the floor to comply with 20.2.4.2, 38.2.4.1 & 7.4.1.1.

B. On 08/02/18 at 10:05 AM while in the company of the FOM, it was observed that the visibility of the exit sign near the 12th floor level Prep/recovery bay #2 was obstructed by other signage and not in compliance with 7.10.1.8.

Based on observation, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

On 07/31/18, at 1:34 PM while accompanied by the PMCPO, observation determined that the sign at Third Floor Exit Stair B reads "STAIR" and not "EXIT" as required by 7.10.3.1.

Based on observation, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

On 08/01/18, while accompanied by the PMCPO, observation determined that signs exist which read "STAIR" and not "EXIT" as required by 7.10.3.1.

Locations include:

A. 10:52 AM: Twelfth Floor landing, Exit Stair F.
B. 10:55 AM: Twelfth Floor landing, Exit Stair E.
C. 11:05 AM: Eleventh Floor landing, Exit Stair F.

D. 11:10 AM: Eleventh Floor landing, Exit Stair E.

Based on observation, 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. On 07/30/18 at 2:45 PM while accompanied by the SFM, it was observed that the 17th Floor Chiller Room leading to STAIR A lacks an exit sign. This does not comply with 7.5.1.1.1.

B. On 07/30/18 at 2:30 PM while accompanied by SFM, it was observed that the designated Exit Stair next to the Boiler Room was observed with a "STAIR" sign instead of the appropriate wording "EXIT". This does not comply with 7.10.3.1.

Based on observation, vertical openings between floors are not protected in accordance with Code requirements. Failure to protect vertical openings between floor can permit fire/smoke conditions to migrate to other floor levels during an emergency situation.

Findings include:

A. On 07/30/18 at 1:50 PM while in the company of the FOM, it could not be confirmed that four 4" conduits through the floor were sealed at IT/Storage room L-734D to prevent the passage of smoke to the floor above to comply with 19.3.1.1 and 8.6.3(1).

B. On 08/01/18 at 1:00 PM while in the company of the FOM, it was observed that the corridor door to Mechanical room 6-714 (which forms a part of the shaft enclosure) is not provided with positive latching hardware to comply with 8.3.3 and 8.3.4. The manual flush bolt for the inactive door was not functional and in the open position.

C. On 08/01/18 at 1:15 PM while in the company of the FOM, it was observed that the east corridor door at Mechanical room 6-516 (which forms a part of the shaft enclosure) was not self-closing to a latched condition to comply with 8.3.3 and 8.3.4.

D. On 08/01/18 at 1:35 PM while in the company of the FOM, it was observed that the east corridor door at Mechanical room 6-518 (which forms a part of the shaft enclosure) was not positive latching to comply with 8.3.3 and 8.3.4 due to unlatched manual flush bolts.

Based on observation, vertical openings between floors are not protected in accordance with Code requirements. Failure to protect vertical openings between floor can permit fire/smoke conditions to migrate to other floor levels rather than being contained in the event of an fire/smoke emergency.

Findings include:

On 08/01/18 at 2:50 PM while accompanied by the SFM, it was observed that the access panel to the ventilation shaft at Admin A Room 12-2308 - 12th Floor was not self-closing to a latched condition to comply with 8.3.3. and 8.3.4.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire emergency.

Findings include:

On 07/31/18 while accompanied by the ACE, observation determined that storage rooms contain sufficient combustible material to constitute high hazard areas. These room doors were observed to not be positive latching due to damaged doors, which does not comply with 39.3.2.1.

Locations include:

A. At 10:00 AM: Fourth Floor Fresenius Medical Care Storage room.

B. At 10:10 AM: Fourth Floor Storage room 4-259.

Based on observation and staff interview, hazardous areas are not protected in accordance with Code requirements. Failure to provide protection of areas with a higher degree of hazard than normal to the remaining occupancy can compromise the safety of all occupants during a fire/smoke event originating within the hazardous area.

Findings include:

A. While accompanied by the FOM, it was observed that Hazardous Areas are not protected in accordance with 19.3.2.1, 8.7.1.2, 8.4.3.5 and NFPA 80-2010, 6.1.4.

Locations and conditions include:

1. On 07/30/18 at 1:50 PM, the corridor door to IT/Storage room L-734D was not self-closing to a latched condition.

2. On 07/31/18 at 1:33 PM, the Patient Escort Storage room M528 door was not self-closing. The coordinator and flush bolts provided were not functional.

3. On 08/01/18 at 11:10 AM, the Urology Equipment Storage room doors lacked automatic flush bolts to provide positive latching for the doors.

4. On 08/01/18 at 1:45 PMm the OR Material Management Tech Supply room 6-210 rated corridor door lacked a closer.


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B. While accompanied by the CPM, it was determined that the facility failed to maintain Hazardous Enclosures if the door to a hazardous room does not close properly to prevent smoke and fire from entering the egress corridor.

Locations and conditions include:

1. On 07/31/18 at 9:10 AM, it was determined that on the 13th floor, West Medical Unit, Soiled Utility Room, Door 13-514 did not latch to the door frame when tested. This does not comply with 19.3.2.1.

2. On 07/31/18 at 9:10 AM, it was determined that on the 12th floor, West Medical Unit, Soiled Utility Room, Door 12-516 did not latch to the door frame when tested. This does not comply with 19.3.2.1.

3. On 07/31/18 at 2:05 PM, it was determined that on the 10th floor, West Medical Unit, Storage Room, door 10-550 did not contain a door label identifying it to be rated for 1-hour. This does not comply with 19.3.2.1.

4. On 07/31/18 at 2:20 PM, it was determined that on the 10th floor, East Medical Unit, Research Lab 10-754A could not be determined that a portion of the lab was enclosed with a 1-hour rated wall. The lab uses combustible materials for testing. Above the ceiling it was identified that the portion of the south and west lab walls contained unprotected openings. The facilities life safety plans did not identify all of the lab walls as fire rated. This does not comply with 19.3.2.1.

5. On 08/01/18 at 2:23 PM, it was determined that on the 7th floor, Environmental Service Room 7-329, the north 1-hour rated wall contained the following deficiencies in noncompliance with 19.3.2.1.

a. 12" diameter hole in wall.
b. No fire stopping material was installed around a 12"x12" duct.
c. (2) ¾" conduits were not fire stopped.

Based on observation, hazardous areas are not protected in accordance with Code requirements. Failure to provide protection of areas with a higher degree of hazard than normal to the remaining occupancy can compromise the safety of all occupants during a fire/smoke event originating within the hazardous area.

Findings include:

A. On 08/02/18 at 9:30 AM while in the company of the FOM, it was observed that the Storage room 11-103 pair of doors did not have a functional coordinator to permit the doors to close and latch in proper sequence to provide separation of the room from the corridor to comply with 20.3.2.1, 38.3.2.1, 8.7.1.2, 8.4.3.5 and NFPA 80-2010, 6.1.4.

B. On 08/02/18 at 9:35 AM while in the company of the FOM, it was observed that the Equipment Storage room 11-129 pair of doors were equipped with closers which held the doors open longer than 100 seconds. The doors could not be forced closed due to the closer resistance. This extended closure time does not comply with 20.3.2.1, 38.3.2.1, 8.7.1.2, 8.4.3.5, 7.2.1.8 & 7.2.1.9 which limits the hold-open period to 30 seconds.

C. On 08/02/18 at 10:00 AM while in the company of the FOM, it was observed that the Equipment Storage room 12-129 pair of doors were equipped with closers which held the doors open longer than 100 seconds. The doors could not be forced closed due to the closer resistance. This extended closure time does not comply with 20.3.2.1, 38.3.2.1, 8.7.1.2, 8.4.3.5, 7.2.1.8 & 7.2.1.9 which limits the hold-open period to 30 seconds.

D. On 08/02/18 at 9:45 AM while in the company of the FOM, it was observed that the Dry Goods Storage room 12-127 door was not self-closing to a latched condition to comply with 20.3.2.1, 38.3.2.1, 8.7.1.2, 8.4.3.5 and NFPA 80-2010, 6.1.4.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Findings include:

On 08/01/18, while accompanied by the PMCPO, observation determined that storage rooms contain sufficient combustible material to constitute high hazard areas. These rooms were observed to lack minimum 1 hour fire ratings required by 19.3.2.1.

Locations include:
A. 2:39 PM: Eighth Floor Storage Room 8-147A.

B. 3:02 PM: Seventh Floor Storage Room 7-247.

Based on 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:

A. On 07/31/2018 at 2:15 PM while in the company of the SFM, the 1st floor level area shown as Vacant room #01-2104 was observed to be used for storage of items including paper products, cardboard boxes, plastic covered items. The amount of combustibles requires protection to comply with 19.3.2.1.2, 19.3.2.1.5 (7), 8.4 and 8.7.1.1 for large storage rooms in a healthcare building.

B. On 08/01/2018 at 3:10 PM while in the company of the SFM, the 10th floor Elevator Lobby for elevators #15, 14 and 13 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 which does not comply with 19.3.2.1.

Based on observation, the the facility failed to provide for all piped-in medical gas systems to be installed and maintained code compliant. This condition could hinder the efficient shut off of any system in an emergency which will affect patients and staff within the immediate location.

Findings include:

A. On 08/01/2018 at 2:30 PM while accompanied by the SFM, the location of the medical gas shut off valve for an Operating Room (OR) was observed to also serve the adjacent NICU Pod. This condition does not comply with NFPA 99, 2010, 5.1.4.8.7 and 5.1.4.8.7.2.

Locations include:

1. 10th floor med gas shut off valve on wall of corridor #T10039 adjacent to OR #1088

B. On 08/01/2018 at 1:30 PM while accompanied by the SFM, medical gas shut off valves serving patient rooms were observed to lack labeling of all rooms served. The identifying graphic located adjacent to each shut off valve does not reflect current conditions and does not comply with NFPA 99, 2010, 5.1.4.8.8 and 5.1.11.2.

Locations include:

1. 4th floor - ZVB 4.1.2.1(adjacent to infusion area)

2. 11th floor - ZVB 11.4.3.1, ZVB 11.1.3.1 and ZVB 11.2.3.1

Based on observation, not all fire alarm initiation devices are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, the fire alarm could fail to activate under emergency conditions.

Findings includes:

A. On 07/31/18 while accompanied by the ACE, observation determined that fire alarm initiating devices (smoke detectors) are located so that airflow from supply air diffusers within 3'-0" of them, prevent their operation as prohibited by NFPA 72 2010 17.7.4.1.

Locations include:

1. At 8:50 AM: Public elevator lobby - 2 devices.

2. At 9:18 AM: Storage room ( Fresenius Medical Care) -1 device.

3. At 9:35 AM: Storage room 4.259 - 1 device.


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B. On 07/31/18 while accompanied by the PMCPO, observation determined that fire alarm initiating devices (smoke detectors) are located so that airflow from supply air diffusers within 3'-0" of them, prevent their operation as prohibited by NFPA 72 2010 17.7.4.1.

Locations include:

1. At 8:52 AM: Mezzanine Laboratory M220, 2 devices.

2. At 8:57 AM: Mezzanine Laboratory M230, 1 device.

3. At 9:01 AM: Mezzanine Laboratory M530, 1 device.

Based on observation and staff interview, fire alarm system components are not installed in accordance with Code requirements. Failure to install components in accordance with requirements can result in failure of the system to operate as intended to notify staff in the event of an emergency and aid in maintenance of the system.

Findings include:

A. On 07/31/18 at 10:20 AM while in the company of the FOM, it was observed that the Fire Alarm Control Panel was not labeled to identify the electrical circuit and panel from which it was fed to comply with NFPA 72-2010, 10.5.5.2.1.

B. On 08/01/18 at 9:10 AM while in the company of the FOM, it was observed that the 4th floor On-call rooms along corridor 4-710 (NE corner of building) lacked visual notification devices to comply with NFPA 72-2010, 18.5.4.6.1.

C. On 08/01/18 at 1:55 PM while in the company of the FOM, it was observed that the 6th floor On-call rooms along corridor 6-502V (within the locker room suite) lacked visual notification devices to comply with NFPA 72-2010, 18.5.4.6.1.


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D. On 07/31/18 at 2:50 PM, while accompanied by CPM, it was determined that on the 9th floor, East Medical Unit, Corridor 9-757 contains four on-call sleeping rooms 9-724, 9-750, 9-752 and 9-754. The on-call rooms did not contain a visual notification device. This does not comply with NFPA 72-2010, 18.5.4.6.1.

E. On 08/01/18 at 9:06 AM, while accompanied by CPM, it was determined that on the 9th floor, West Medical Unit, Corridor 9-547 contains four on-call sleeping rooms 9-522, 9-546, 9-548 and 9-550. The on-call rooms did not contain a visual notification device. This does not comply with NFPA 72-2010, 18.5.4.6.1.

F. On 08/01/18 at 9:55 AM, while accompanied by CPM, it was determined that on the 8th floor, East Medical Unit, Corridor 8-771 contains four on-call sleeping rooms 8-726, 8-764, 8-766, 8-768. The on-call rooms did not contain a visual notification device. This does not comply with NFPA 72-2010, 18.5.4.6.1.

G. On 08/01/18 at 10:25 AM, while accompanied by CPM, it was determined that on the 7th floor, East Medical Unit contains four on-call sleeping rooms 7-726, 7-748, 7-750 and 7-752. The on-call rooms did not contain a visual notification device. This does not comply with NFPA 72-2010, 18.5.4.6.1.

Based on observation, not all portions of the building's fire alarm system are installed to provide notification in staff areas. This condition may prevent emergency egress from the location of fire origin to an adjacent compartment. This condition may affect patients, staff and visitors throughout a smoke compartment.

Findings include:

While accompanied by SFM, it was observed that the Staff On-call rooms lacked visual notification devices to comply with NFPA 72-2010, 18.5.4.6.1.

Locations include:

A. On 07/31/18 at 2:50 PM 14th floor Oncology / Gynecology Room #14-2225.

B. On 08/01/2018, at 2:40 PM 10th floor Resident On-Call Sleep.

Based on observation, not all fire alarm control functions are installed or operate as required. This deficient practice could affect patients, staff, and visitors in the building because the fire alarm system could fail to operate if its controls are not installed and do not function as required.

Findings include:

On 08/01/18, while accompanied by the PMCPO, observation determined that the breaker serving the Fire Alarm Control Unit is not labeled "FIRE ALARM," as required by NFPA 72 2010 10.5.2.2, and that the breaker serving the Fire Alarm Control Unit is not provided with red marking, as required by NFPA 72 2010 10.5.2.3.

Locations include:

A. 10:40 AM: The Life Safety Panel located in Thirteenth Floor Electrical Closet A-1.

B. 10:42 AM: The Life Safety Panel located in Thirteenth Floor Electrical Closet A-2.

C. 1:29 PM: The Life Safety Panel located in Tenth Floor Electrical Closet A-2.

D. 2:08 PM: The Life Safety Panel located in Ninth Floor Electrical Closet A-2.

Based on document review and interview, the facility failed to provide a properly functioning fire alarm system. This deficient practice could affect patients, staff and visitors if the fire alarm system failed to function properly during a fire event.

Findings include:

On 08/01/18 between 11:30 AM - 1:00 PM document review of the fire alarm system testing identified that 46 fire alarm batteries failed during the last annual testing. An interview with CPM indicated that the batteries have not been replaced at the time of this survey. This does not comply with NFPA 72, 10.5.7.1.

Based on document review and interview, the facility failed to provide a properly functioning fire alarm system. This deficient practice could affect patients, staff and visitors if the fire alarm system failed to function properly during a fire event.

Findings include:

On 08/01/18 between 11:30 AM - 1:00 PM document review of the fire alarm system testing identified that 128 fire alarm batteries failed during the last annual testing. An interview with CPM indicated that the batteries have not been replaced at the time of this survey. This does not comply with NFPA 72-2010, 10.5.7.1.

Based on document review and interview, the facility failed to provide a properly functioning fire alarm system. This deficient practice could affect patients, staff and visitors if the fire alarm system failed to function properly during a fire event.

Findings include:

On 08/01/18 between 11:30 AM - 1:00 PM document review of the fire alarm system testing identified that 46 fire alarm batteries failed during the last annual testing. An interview with CPM indicated that the batteries have not been replaced at the time of this survey. This does not comply with NFPA 72-2010, 10.5.7.1.

Based on observation, the facility failed to provide a complete automatic sprinkler system. This deficient practice could affect patients, staff, and visitors in the building because the automatic sprinkler system may fail to extinguish a fire if it is not properly installed.

Findings include:

A. On 07/31/18 while accompanied by the ACE, observation determined that the sprinkler heads at the following locations are not installed as required.

1. At 9:55 AM: At the Fourth Floor Fresenius Medical Care Storage Room, escutcheon rings were observed to be missing from three pendent sprinkler heads to comply with NFPA 13-2010, 6.2.7 and NFPA 25-2011 5.2.1.1.2(3).

2. At 9:58 AM: At the Fourth Floor Fresenius Medical Care Storage Room, storage boxes stacked on the shelves to less than 18 inches from the sprinkler heads as prohibited by NFPA 13-2010, 8.5.6.1.

Based on observation and staff interview, the facility failed to install a complete building fire sprinkler system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

Findings include:

A. On 07/30/18 at 2:10 PM while in the company of the FOM, it was observed near door L-726 that the sprinkler head & above ceiling piping was being supported by the ceiling system and not independently from the structure to comply with NFPA 13-2010, 9.2.1.3.

B. On 08/01/18 at 9:58 AM while in the company of the FOM, it was observed that the Equipment closet, adjacent IR 4-727, lacked sprinkler coverage below the suspended equipment to provide coverage to comply with NFPA 13-2010, 8.6.5.3.


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C. On 07/30/18 at 1:45 PM in the company of the CF/G, it was observed there is a lack of fire sprinkler protection for all of the facilities traction elevator machine rooms. NFPA 13, 2010, 8.1.1


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D. On 08/01/18 at 1:20 PM, while accompanied by CPM, it was determined that on the 7th floor, Operating Suite, Cart Lift Elevator Machine Room was not installed with a sprinkler head. This does not comply with NFPA 13-2010, 8.15.5.3.

Based on observation, the facility failed to install a complete building automatic fire sprinkler protection system. This deficient practice could result in delayed response and suppression during a fire event, which may affect patients, staff, and visitors in the building if the automatic sprinkler system failed to extinguish a fire if it is not properly installed.

Findings include:

A. On 08/01/18 at 10:47 AM, while accompanied by the PMCPO, observation determined that a large gap exists in the acoustic ceiling system at the Thirteenth Floor Lobby, above the large wood sliding door, thus compromising the coverage of the room by standard pendant or upright spray sprinkler heads, as prohibited by NFPA 13 2010 8.6.4.1.1, because the activation of the sprinkler heads could be delayed due to heat rising past them.


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B. On 08/01/18 at 2:00 PM in the company of the CF/, the lack of fire sprinkler protection was observed for all of the facility's traction elevator machine rooms. NFPA 13, 2010, 8.1.1

Based on observation and staff interview the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

Findings include:

A. On 08/01/18 at 9:00 AM in the company of the CF/G, the lack of fire sprinkler protection was observed for all of the facility's traction elevator machine rooms. NFPA 13, 2010, 8.1.1

B. On 08/01/18 at 11:00 AM in the company of the CF/G, it was observed at the 7th Floor Mechanical Room 07-2105 that sprinkler protection has been removed from beneath a ventilation duct more than 4 feet in width leading to Shaft T7003. NFPA 13, 2010, 8.6.5.3.3

Based on observation and interview, the facility failed to inspect and maintain the facility's fire protection sprinkler system. This deficient practice could affect patients, staff and visitors if the sprinkler system did not perform properly during a fire event due to a lack of proper maintenance.

Findings include:

A. On 07/30/18 at 2:15 PM while in the company of the FOM, it was observed at Bed Storage L-724 that a sprinkler head escutcheon was missing and not in compliance with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3).

B. On 07/31/18 at 1:35 PM while in the company of the FOM, it was observed that ceiling tile was missing at the IT room M-530A adjacent Stair D to comply with NFPA 13-2010, 8.6.4.

C. On 08/01/18 at 2:30 PM while in the company of the FOM, it was observed outside the 6th floor CSS ETO rooms that a sprinkler escutcheon was missing and not in compliance with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3).


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D. On 07/30/18 at 1:50 & 1:55 PM in the company of the CF/G, it was observed the top of stair sprinkler heads are obstructed by masking tape in noncompliance with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3)/(6) at the following locations:
1. Stair 17D
2. Stair 18B


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E. On 07/31/18 at 9:25 AM, while accompanied by CPM, it was determined that on the 12th floor, East Medical Unit, South Corridor 12-721 contained a sprinkler head in the ceiling that was missing the protective escutcheon plate. This does not comply with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3).

F. On 08/01/18 at 9:22 AM, while accompanied by CPM, it was determined that on the 8th floor, East Medical Unit, South Corridor 12-721 contained a sprinkler head in the ceiling that was missing the protective escutcheon plate. This does not comply with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3).

G. On 08/01/18 at 10:05 AM, while accompanied by CPM, it was determined that on the 8th floor, East Medical Unit, Southeast Supply room adjacent to door 8-736 contained a sprinkler head in the ceiling that was missing the protective escutcheon plate. This does not comply with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3).

H. On 08/01/18 at 10:30 AM, while accompanied by CPM, it was determined that on the 7th floor, East Medical Unit, Stair "C" contained a sprinkler head under the 8th floor landing that was painted. This does not comply with NFPA 25-2011, 5.2.1.1.2(6).

I. On 08/01/18 at 10:35 AM, while accompanied by CPM, it was determined that on the 7th floor, East Medical Unit, Equipment room 7-772 contained a sprinkler head in the ceiling that was missing the protective escutcheon plate. This does not comply with NFPA 13-2010, 6.2.7 and NFPA 25-2011, 5.2.1.1.2(3).

J. On 08/01/18 at 1:39 PM, while accompanied by CPM, it was determined that on the 7th floor, Operating Suite, Sterile Processing room, south row of storage, contained an escutcheon plate that was painted. This does not comply with NFPA 25-2011, 5.2.1.1.2(6).

K. On 08/01/18 at 2:02 PM, while accompanied by CPM, it was determined that on the 7th floor, Specimen Receiving Lab, south side of the room contained an escutcheon plate that was partially imbedded into the ceiling tile. This condition could prevent the proper activation of the sprinkler head. This does not comply with NFPA 25-2011, 5.2.1.1.2(3).

L. On 08/01/18 at 2:10 PM, while accompanied by CPM, it was determined that on the 7th floor, Specimen Receiving Lab, south side of the room contained a damaged ceiling tile adjacent to a sprinkler head. This condition could prevent the proper activation of the sprinkler head. This does not comply with NFPA 13-2010, 8.6.4.1.1.1.

M. On 08/01/18 at 2:15 PM, while accompanied by CPM, it was determined that on the 7th floor, Specimen Receiving Lab, Histology Tissue Lab contained 2 escutcheon plates that were corroded. This does not comply with NFPA 25-2011, 5.2.1.1.2(2).

Based on observation, the facility failed to install and maintain automatic sprinkler protection in accordance with the code requirements. This deficient practice could impair activation of a sprinkler head and delay an emergency response.

Findings include:

A. On 07/31/18 while accompanied by the SFM, it was observed that the sprinkler head escutcheons were missing in noncompliance with NFPA 25 2011 5.2.1.1.2(3).

Locations include:

1. At 1:30 PM in the Respiratory Equipment Room 15-2233 of the 15th Floor.

2. At 2:00 PM in the Soiled Utility Room 09-2112 of the 9th Floor Ante-Partum Unit (North End).

3. At 2:15 PM in Locker Room (Women) near Lockers 257 and 249.

4. At 10:30 AM in the exit access corridor in the 7th Mezzanine near the Mechanical Room.

B. On 07/31/18 at 1:00 PM while accompanied by the SFM, at the 16th Floor exit access corridor by the Rehab Office 16-2121, sprinkler heads were observed covered with accumulation of lint and dust which does not comply with NFPA 25 2011, 5.2.1.1.2(5).

Based on observation and staff interview, spaces open to the exit access corridor are not provided with protective features in accordance with Code requirements. Failure to provided protective features can compromise the use of the corridor when prompt notification of a fire/smoke event occurring within the space open to the corridor is not provided.

Findings include:

A. On 08/01/18 at 10:10 AM while in the company of the FOM, it was observed that the waiting area open to corridor 4-519A outside Outpatient Radiology at corridor 4-321A was not provided with smoke detection to comply with 19.3.6.1(2)(b).

B. On 08/01/18 at 10:35 AM while in the company of the FOM, it was observed that the waiting area open to corridor at the Visitor elevator lobby reception area 5-500B was not provided with smoke detection to comply with 19.3.6.1(2)(b).

C. On 08/01/18 at 10:38 AM while in the company of the FOM, it was observed that Waiting area 5-507 open to corridor was not provided with smoke detection located at the high ceiling areas to comply with 19.3.6.1(2)(b) and NFPA 72-2010, 17.7.3.2.1. The smoke detectors provided are mounted at the bottom of the headers in the ceiling approximately 18" below the plane of the high ceiling areas.

D. On 08/01/18 at 10:40 AM while in the company of the FOM, it was observed that the table & chair waiting area along corridor 5-301A was not provided with smoke detection to comply with 19.3.6.1(2)(b).

E. On 08/01/18 at 1:50 PM while in the company of the FOM, it was observed that the table & chair waiting area along corridor 6-307 outside the CSS department was not provided with smoke detection to comply with 19.3.6.1(2)(b).

Based on observation, not all use areas are separated from exit access corridors as required. These deficiencies could affect patients, staff, or visitors in the building because smoke or fire could pass from the use areas into the remainder of the building.

Findings include:

On 08/02/18 at 9:48 AM, while accompanied by the PMCPO, observation determined that Lower Concourse Waiting Room L178, which is open to a corridor, lacks a smoke detector required by 19.3.6.1(2)(b).

Based on observation and interview, the facility failed to maintain a smoke-tight corridor door. This deficient practice could affect patients, staff and visitors if smoke from a room located on an egress corridor did not have a door that properly closed to the frame.

Findings include:

On 07/30/18 at 2:15 PM while accompanied by SFM, the 17th floor, Boiler Room Plant Office, 17-22212 egress door was observed to be equipped with an unapproved hold open device (wood peg). This does not comply with 19.3.6.3.2.

Based on observations and interviews, the facility failed to maintain corridor doors. This deficient practice could affect patients, staff and visitors if smoke from a room located on an egress corridor did not have a door that properly closed to the frame.

Findings include:

A. On 07/30/18 at 2:15 PM, while accompanied by CPM, it was determined that on the 16th floor, Report Room, door 16-530 did not close and latch to the frame when tested. This does not comply with 19.3.6.3.

B. On 07/30/18 at 2:20 PM, while accompanied by CPM, it was determined that on the 15th floor, Equipment Room, door 15-510 did not close and latch to the frame when tested. This does not comply with 19.3.6.3.

C. On 07/30/18 at 2:22 PM, while accompanied by CPM, it was determined that on the 15th floor, Environmental Services Room, door 15-526 did not close and latch to the frame when tested. This does not comply with 19.3.6.3.

D. On 07/30/18 at 2:25 PM, while accompanied by CPM, it was determined that on the 15th floor, Medical Work Room, door 15-756 did not close and latch to the frame when tested. This does not comply with 19.3.6.3.

E. On 07/31/18 at 3:00 PM, while accompanied by CPM, it was determined that on the 9th floor, East Medical Unit, double doors adjacent to stair "C" did not close and latch to the door frame when tested. This does not comply with 19.3.6.3.

F. On 08/01/18 at 9:15 AM, while accompanied by CPM, it was determined that on the 9th floor, East Medical Unit, double doors adjacent to Soiled Utility room 9-514 did not close and latch to the door frame when tested. This does not comply with 19.3.6.3.

G. On 08/01/18 at 9:35 AM, while accompanied by CPM, it was determined that on the 8th floor, Medical Unit, double doors adjacent to room 8-327 did not close and latch to the door frame when tested. This does not comply with 19.3.6.3.

H. On 08/01/18 at 1:35 PM, while accompanied by CPM, it was determined that on the 7th floor, Operating Suite, Equipment Storage door 7-533 did not close and latch to the frame when tested. This does not comply with 19.3.6.3.

I. On 08/01/18 at 1:50 PM, while accompanied by CPM, it was determined that on the 7th floor, Operating Suite, Equipment Storage door 7-533 did not close and latch to the frame when tested. This does not comply with 19.3.6.3.

J. On 08/01/18 at 1:1:00 PM, while accompanied by CPM, it was determined that on the 7th floor, Blood Bank, north door to public corridor 7-303 did not close and latch to the frame when tested. This does not comply with 19.3.6.3.

Based on observation, corridor wall openings are not maintained to provide protection of the exit access corridor. Failure to protect the exit access corridor from exposure from a fire/smoke event in an adjoining room can compromise the use of the corridor as a means of egress during a fire/smoke event.

Findings include:

On 08/01/18 at 10:30 AM while in the company of the FOM, it was observed, at the OR Pharmacy 5-521 transaction window on the corridor 5-760A side, that the shutter provided did not have smoke detection on either side within 5' to actuate the shutter to close upon detection of smoke to comply with 19.3.6.5.1 and NFPA 72-2010, 17.7.5.6.

Based on observation, not all smoke barriers are constructed and maintained as required. This deficient practice
could affect patients, staff, and visitors in the building because smoke could pass between adjacent smoke compartments if the smoke barriers are not properly constructed.

Findings include:

A. On 08/01/18 at 11:00 AM while accompanied by the ACE,observation determined that conduit sleeves on Eight Floor above the ceiling at the west pair of exit doors are not sealed against the passage of smoke as required by 8.5.6.2.


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B. On 08/01/18 at 9:47 AM while accompanied by the PMCPO, observation determined that conduit sleeves in the smoke barrier wall, above the ceiling in Thirteenth Floor Corridor G13-100, are not sealed against the passage of smoke as required by 8.5.6.2.

Based on observation, Smoke Barriers are not maintained to resist the passage of smoke. Failure to maintain Smoke Barriers will permit smoke to migrate from one smoke compartment to another and compromise the effectiveness of the barrier to provide an area of refuge during a fire/smoke event.

Findings include:

On 07/31/18 at 10:00 AM while in the company of the FOM, it was observed that the designated 2-hour fire/smoke barrier wall above the double egress doors between the Kitchen areas had transfer grilles below the ceiling which were not equipped with smoke dampers to comply with 19.3.7.3 and 8.5.5.2. Only fusible link fire dampers appeared to be provided which do not close to resist the passage of smoke.

Based on observation, not all smoke barrier doors are installed and maintained as required. This deficient practice could affect patients. staff, and visitors in the hospital because smoke could pass between adjacent smoke compartments if smoke barrier doors are not properly installed and maintained.

Findings include:


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On 08/02/18 at 9:37 AM while accompanied by the PMCPO, the cross-corridor doors located just south of Lower Concourse Exit Stair E did not fully close, as required by 19.3.7.8(1), because the latching hardware on the door is out of adjustment.

Based on observation and interview, the facility failed to maintain smoke barrier doors. This deficient practice could affect patients, staff and visitors if smoke from one smoke compartment was permitted to pass through barrier doors into the adjacent smoke compartment due to improper door closing.

Finding includes:

On 07/30/18 at 1:51 PM, while accompanied by CPM, it was determined that on the 16th floor, cross corridor smoke doors 16-716 did not close to the frame due to the head of the door catching on the frame. This does not comply with 19.3.7.6.

Based on observation, the facility failed to install its ventilation system in the required manner. This deficient practice could affect patients, staff, and visitors in the hospital because smoke and fire could be permitted to move between building stories and fire compartments if the system is not properly installed.

Findings include:

A. On 08/01/18, at 9:20 AM while accompanied by the ACE, observation determined that Thirteenth Floor ventilation shafts are not protected as required by 8.3.1.2.

Locations include:

1. At the Southeast Ventilation Shaft, the west wall does not extend to the underside of the deck above, leaving a gap of approximately 12 inches for the entire length of the shaft.

2. At the Southwest Ventilation Shaft, the west wall of the shaft enclosure is not verified to be rated.

B. On 08/01/18, at 9:20 AM while accompanied by the ACE, observation determined that duct penetrations at ventilation shafts are not protected as required by 19.3.1.

Locations include:

1. At the the Tenth Floor Southwest Ventilation Shaft, a duct was observed that lacks the retaining angles required for compliance with UL 555, thus not complying with 8.3.5.7 and NFPA 90A-2012, 5.3.4.6.


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C. On 08/01/18 at 9:42 AM, while accompanied by the PMCPO, observation determined that a fire damper at a duct, penetrating the ventilation shaft enclosure located in Thirteenth Floor Room G13-200, are not installed correctly as required by 8.3.5.7, 9.2.1, and NFPA 80-2010, 19.2.1.6.1 because the installation lacks sheet metal angles.


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D. On 08/01/18 at 9:35 AM, while accompanied by CPM ,it was determined that on the 6th floor, A2 Mechanical Room contained combustible storage throughout this room. This does not comply with NFPA 90A-2012, 5.3.4.5.

Based on observation, the facility failed to provide access to fire protection appliances within the ventilation duct system. Failure to install and maintain this installation could result in the passage of fire and products of combustion from one fire compartment to another. This deficient practice could affect patients, staff and visitors during a fire event.

Finding includes:

A. On 08/01/18 at 8:50 AM in the company of the CF/G, it was observed that the installed access doors located at Lower Concourse Corridor TL 010 for inspection and maintenance of the above-ceiling through-the-floor fire dampers from Shaft T1075 are partially imbedded in the corridor wall not allowing access to the fire protection devices within. Document review of the fire damper inspections does not identify these as inaccessible. NFPA 80-2010, 19.2.3


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B. On 07/30/18 at 1:49 PM, while accompanied by CPM, it was determined that on the 16th floor, IT Room 16-726 contained a 2-hour rated fire damper that was not installed properly. Fire rated caulking was installed around the perimeter of the damper housing. This installation can prevent the fire damper from properly closing. This does not comply with 19.5.2.1.9.2, NFPA 80-2010 19.2.1.4.1.

C. On 07/31/18 at 9:15 AM, while accompanied by CPM, it was determined that on the 13th floor, Public Corridor, East Electrical Room, Louver not installed at 2-hour rated fire damper exposing the annular space around the damper to be open to the adjacent room. This does not comply with 19.5.2.1.9.2, NFPA 80-2010, 19.2.1.1.1.

D. On 07/31/18 at 11.25 AM, while accompanied by CPM, it was determined that on the 11th floor, East Medical Unit, IT Room, Louver not installed at 2-hour rated fire damper exposing the annular space around the damper to be open to the adjacent room. This does not comply with 19.5.2.1.9.2, NFPA 80-2010, 19.2.1.4.1.

E. On 07/31/18 at 2:15 PM, while accompanied by CPM, it was determined that on the 10th floor, East Medical Unit, Electrical Room 10-750, Louver not installed at 2-hour rated fire damper exposing the annular space around the damper to be open to the adjacent room. This does not comply with 19.5.2.1.9.2, NFPA 80-2010, 19.2.1.4.1.

F. On 08/01/18 at 1:30 PM, while accompanied by CPM, it was determined that on the 7th floor, Operating Suite, IT Room 7-525A contained a 2-hour rated fire damper that was not installed properly. Fire rated calking was installed around the perimeter of the damper housing. This installation can prevent the fire damper from properly closing. This does not comply with 19.5.2.1.9.2, NFPA 80-2010, 19.2.1.4.1.

Based on an observation it was determined that the facility failed to properly manage and maintain the existing Air-conditioning and Ventilating Systems. This deficient practice could affect patients, staff and visitors if fire dampers are not installed in wall locations to limit the fire and smoke from a fire event in hazardous areas.

Findings include:

A. On 08/01/2018 at 9:36 AM, while in the company of the SFM, the 8th floor electrical equipment room #08-2107 with a designated 2-hour fire rating, contains a through wall dampered duct penetration with a wall grill. The perimeter of the grill is sealed with caulk. The installation does not comply with NFPA 90A 2012, 5.3.1.2 to maintain a 2-hour fire rating.

B. On 08/01/2018 at 2:00 PM while in the company of the SFM, multiple ducts, pipes, conduits penetrating the bottom of a 2-hour rated shaft enclosure were observed. The installation of ductwork through the bottom of a vertical shaft is not installed in accordance with the condition of their listing. Metal duct is non flammable and therefore has an Underwriters Lab, UL 181 Flame Spread Rating of zero. This does not comply with 8.3.5.7, 9.2.1, NFPA 90A 2012, 5.4.4 and 5.4.7.1 along with the requirements of NFPA 80, 2010.

Locations include:

1. 11th floor Tray return room
2. 11th floor Administration office #11-2106

Based on observation, the facility failed to comply with the requirements for a hazardous room with a single designation. By allowing areas/rooms to serve multiple functions the spread of smoke and fire throughout a smoke compartment is increased and the evacuation of patients, staff and visitors is delayed.

The findings are:

A. On 07/31/2018 at 10:10 AM while accompanied by the SFM, Trash Collection room # 00-2226 was observed being used for a purpose other than what the code allows. The room contains a hot water return pump which is not connected to the function/use of the room. This installation does not comply with 19.5.4.4.

B. On 07/31/2018 at 9:06 AM while accompanied by the SFM, Trash collection room # 00-2226, the chute discharge door was observed with trash piled to the bottom of the door and covering the fusible link. This condition does not comply with NFPA 82, 2009, 10.2.1 for a clear and unobstructed door at all times.

Based on observation, the facility failed to provide a compliant Category 1 medical compressed air system. This deficient practice could result in contamination of this patient use system.

Finding includes:

On 07/31/18 at 10:50 AM in the company of the CF/G, it was observed in the 6th Floor Mechanical Room 6-516 that the intake for the patient medical air compressors is installed in the supply side plenum of surgical air handlers which contain electric fan motors in noncompliance with NFPA 99, 2012, 5.1.3.6.3.12.

Based on observation, the facility failed to provide a compliant Category 1 medical compressed air system. This deficient practice could result in contamination of this patient use system.

Findings include:

On 08/01/18 at 2:10 PM in the company of the CF/G, it was observed that at the 16th Floor Mechanical Room 16-0007 the intake for the patient medical air compressors is installed in the supply side plenum of an air handler which contain electric fan motors in noncompliance with NFPA 99, 2012, 5.1.3.6.3.12.

Based on observation, the facility failed to install and maintain its piped-in medical gas system in the manner required. This deficient practice could affect patients, staff, and visitors in the building because the medical gas piping system could fail to operate when needed if not properly installed and maintained.

Findings include:

On 07/31/18 at 9:17 AM while accompanied by the PMCPO, observation determined that the door to Medical Gas Manifold Room 2-215 is not positive latching as required by Table 8.3.4.2, NFPA 80 2010 6.1.3 and NFPA 99 2012 5.1.3.3.2(4) because the door hardware is out of adjustment.

Based on observation, not all portions of the building piped medical gas system are installed in accordance with Code requirements. Failure to install medical gas systems in accordance with requirements can result in failure of the system to perform without hazard to the occupants.

Findings include:

A. On 07/31/18 at 10:40 AM while in the company of the FOM, it was observed that the medical gas shut off valves for the 1st floor ED West patient bays labeled as serving 12, 14, 16, 18, 20, & 21 are not separated by a wall between the valve and the outlets forming a separate room to comply with NFPA 99-2012, 5.1.4.8(1) & (3).

B. On 07/31/18 at 11:20 AM while in the company of the FOM, it was observed that the shut off valves for patient bay 15 could not be located to comply with NFPA 99-2012, 5.1.4.8.

Based on observation, not all basic electrical components are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical system could fail to operate properly when needed if the electrical components are not properly installed and maintained.

Findings include:

On 08/02/18, while accompanied by the PMCPO, observation determined that electrical switchgear room doors lack panic hardware required by NFPA 70 2011 450.43(C). Locations observed include:

A. 9:38 AM: Lower Concourse Electrical Switchgear Room L310.

B. 9:40 AM: Lower Concourse Electrical Switchgear Room L312.

C. 9:42 AM: Lower Concourse Electrical Switchgear Room L314.

Based on observation, Critical Branch essential electrical system receptacles are not identified in accordance with Code requirements. Failure to identify receptacles can prevent prompt identification of the panel and circuit from which they are fed to perform maintenance or remedy a loss of power condition promptly.

Findings include:

On 08/01/2018 at 2:20 PM while in the company of the SFM, red critical receptacles in the 10th floor OR room #1088, are not labeled to identify the electrical panel and circuit from which they were fed to comply with NFPA 99-2012, 6.4.2.2.6.2(C) and NFPA 70-2011, 517.19(A).

Based on observation, not all electrical power cords and flexible cords are installed and utilized in the required manner. This deficient practice could affect patients, staff, and visitors in the building because the use of these devices could compromise the emergency electrical systems if they are not used properly.

Findings include:

On 08/02/18 at 9:32 AM, while accompanied by the PMCPO, observation determined that two flexible cords are utilized, in Lower Concourse Copy Room L307, as a substitute for fixed wiring as prohibited by NFPA 70 2011 400.8(1).