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Based upon 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:

On 4/11/17 at 3:30pm while in the company of the VPPS, AA & FS it was observed that the delayed egress locking devices installed at the 2nd floor cross corridor smoke barrier doors lacked the signage required by NFPA 101-2012, 7.2.1.6.1(4).

Based upon observation, exit stairs are not enclosed by fire rated construction in accordance with requirements. Failure to enclose exit stairs can compromise the safety of the exit to provide a protected path to the exterior of the building for any occupants who must use the exit.

Findings include:

A. On 4/12/17 while in the company of the VPPS & FS it was observed that stair enclosure walls were not sealed at miscellaneous penetrations of pipe, conduit or wire in accordance with 8.3.5 to maintain the required fire resistance rating of the enclosing walls. Locations include:

1. At 8:50am unsealed conduit & wire wall penetrations at Stair 4 above the non-rated drywall soffit on the 1st floor were observed.

2. At 9:15am unsealed conduit & insulated pipe at Stair 5 above the non-rated drywall soffit on the 1st floor were observed.

B. On 4/12/17 while in the company of the VPPS & AA it was observed that the Stair door did not close to latch to comply with 7.1.3.2.1(8). Locations observed include:

1. At 9:30am the 1st floor door at Stair #7 did not self-close and latch when the exterior door was open.

2. At 1:25pm the Basement door at Stair #5 did not self-close and latch.

Based on observation during the survey walk-through, not all exit paths are clearly identified. This deficiency could affect all patients in the area of the facility, as well as any staff and visitors present, they could bypass the level of exit discharge and prohibit them from reaching an exit from the building in a timely manner if there is a emergency situation.

Findings include:

A. On 4/12/17 at 2:12 PM while accompanied by ET and AA, it was observed that the stairwell (back staff entrance) continues to the lower level and not equipped with a means to prevent occupants from traveling past the level of discharge into the lower lever. This does not comply with the requirements of NFPA 101 2012, Sections 7.7.3.4.


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B. On 4/12/17 at 10:45am while in the company of the VPPS & FM it was observed that the interrupter gate provided at the 1st floor level of Stair #2 did not rest in a fully closed position in noncompliance with 7.7.3.4.

Based upon observation, Exit signs are not provided to provide clear identification of exit access. Failure to identify available means of egress can result in occupant confusion or inability to reach an exit during if there is a fire/smoke event.

Findings include:

A. On 4/12/17 at 1:25pm while in the company of the FM & AA it was observed that no exit signage was provided on the Basement cross corridor doors near Purchasing to comply with 7.10.1.2.1.

B. On 4/12/17 at 1:25pm while in the company of the FM & AA it was observed that Exit sign #131 in the Basement corridor leading to Stair #5 was not illuminated to comply with 7.10.4 & 7.10.5.

C. On 4/12/17 at 9:00am while in the company of the VPPS & AA it was observed that the exit sign located at the exterior door of the 1st floor Administration Board room was not illuminated to comply with 7.10.4 & 7.10.5.

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

Findings include:

A. On 4/11/17 at 3:00pm while in the company of the VPPS, FS & AA it was observed that the 2-story lobby space does not comply with 19.3.1 & 8.6. The space was indicated as not meeting the requirements of an Atrium (8.6.7) and is not separated from means of egress exit access corridors as required by 8.6.9.1. Adjacent corridors are marked with exit signage which directs the corridors into or through the 2-story space.

B. On 4/12/17 at 1:30pm while in the company of the VPPS, FM & AA it was observed that the Basement East Pump room 050.023 contained a duct through the floor above which was not installed in accordance with tested design details to comply with 19.3.1 and 8.3.5.1.

Based on document review and on site observations of hazardous areas, the facility failed to provide separation between hazardous rooms from surrounding areas. This deficient practice could affect patients, staff and visitors if a fire spread without proper fire separation.

Findings include:

A. On 4/12/17, at 2:08 PM while accompanied by ET and AA, a review of the Life Safety drawings, of the 1st floor Laboratory, indicated rated wall systems from nonrated to 2 hour fire ratings.

1. The room contained unsealed wall penetrations through all wall types above the ceiling. This does not comply with NFPA 101, 8.3.5.

2. The room contained a back door which was not self-closing. This does not comply with NFPA 101, 19.3.2.1.3.


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Based upon direct observation, sprinklered hazardous areas are not separated by smoke resisting construction with self-closing doors. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation can occur.

Findings include:

C. On 4/12/17 at 11:30am while in the company of the VPPS & the Surgery Manager it was observed and indicated by the Surgery Manager that OR #4 is being used for the storage of equipment & supply carts in quantities greater than normal for use as an active OR. Although the doors to OR #4 are self-closing, OR #4 is not enclosed with smoke resisting construction to comply with 19.3.2.1, 8.7.1 & 8.4.

D. On 4/12/17 at 1:25pm while in the company of the VPPS, FM, FS & AA, it was observed that the Basement level EVS corridors and the corridor outside the conference rooms were being used as storage locations which were not separated from means of egress to comply with 19.3.2.1. The corridors were not maintained free of obstructions by stored materials to comply with 7.1.10.1, 7.5.1.6 and 7.5.2.1.

E. On 4/12/17 at 2:05pm while in the company of the FM & AA it was observed that the Loading Dock is a defined path of exit as an extension of the Basement corridor. The dock area contained stored and/or stationary material in noncompliance with 19.3.2.1, 7.5.1.6 and 7.5.2.1.

F. On 4/12/17 at 1:30pm while in the company of the FM & AA it was observed that the IT Storage room door was not self-closing to comply with 19.3.2.1, 8.7.1 & 8.4.

Based upon direct observation, sprinklered hazardous areas are not separated by smoke resisting construction with self-closing doors. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation can occur.

Findings include:

On 4/12/17 at 3:45pm while in the company of the VPPS & FM it was observed that the Janitor room which contained a gas fired water heater was not provided with a self-closing door to comply with 39.3.2.1, 8.7.1.2 & 8.4.3.5.

Based upon observation, fire alarm systems are not installed in accordance with Code requirements. Failure to install the fire alarm system in accordance with Code requirements can compromise the function and/or maintenance of the system intended to provide notification to occupants of a fire/smoke event in the building.

Findings include:

On 4/12/17 at 3:50pm while in the company of the VPPS & FM it was observed that the breakers serving the fire alarm system were not marked in red and provided with lock-on devices to comply with NFPA 72-2010, 10.5.5.2.3 & 10.5.5.2.4. The electrical panel located in the sprinkler riser room accessed from the exterior had circuits identified as serving the fire alarm system that were not marked with red and not provided with lock-on devices.

Based upon observation, fire alarm systems are not installed in accordance with Code requirements. Failure to properly install fire alarm systems can compromise the operation of the system to provide an effective warning if there is a fire/smoke event and affect all occupants of the building.

Findings include:

A. On 4/11/17 at 3:25 while in the company of the VPPS, AA & FS it was observed that the smoke detector located in the ICU Telecom room 264 was not mounted at the ceiling or on a wall within 12" of the ceiling to comply with NFPA 72-2010, 17.7.3.2.1.

B. On 4/12/17 at 8:55am while in the company of the VPPS & FS it was observed that the "1EMLS" electrical panel located at the electrical room near the 1st floor Administration offices served components of the Fire Alarm system. The circuits did not have red markings or lock-on devices to comply with NFPA 72-2010, 10.5.5.2.3 & 10.5.5.2.4.

C. On 4/12/17 at 2:55pm while in the company of the VPPS & FM it was observed that the "EMB" panel in the Basement Mechanical room served components of the Fire Alarm system. The circuits did not have red markings or lock-on devices to comply with NFPA 72-2010, 10.5.5.2.3 & 10.5.5.2.4. It was not clear this was a designated Life Safety Branch panel.

Based on observation during the survey walk-through, not all components of the automatic sprinkler system are installed as required. This deficiency could affect patients, staff, or visitors in the building if the sprinkler system failed to activate in a timely manner during a fire/smoke event.

Findings include:

A. On 4/12/17 at 9:05 AM, while accompanied by ET and AA at the cross corridor doors in 2 South near Room 231, it was observed that not all sprinkler heads are supported within 24" of the head as required by NFPA 13, 2010, 9.2.3.5.1.

B. On 4/12/17 at 9:39 AM, while accompanied by ET and AA on 1st floor along the Radiology / CT hallway is an electrical room. It was observed that the electrical room was not provided with sprinkler protection in accordance with NFPA 101, 2012, 19.3.5.7.


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Based on observation, sprinklers are not provided in all spaces to comply as a fully sprinklered building. Failure to install and maintain a fully sprinklered building could compromise the suppression of a fire affecting all occupants of the building in case of fire event.

Findings include:

C. On 4/11/17 at 3:20pm while in the company of the VPPS, AA & FS it was observed that the shallow electrical closet located in the 2nd floor ICU lacked sprinkler protection and a ceiling or walls to contain or separate it from the remainder of the above ceiling space to comply with NFPA 13-2012, 4.1.

D. On 4/12/17 at 9:50am while in the company of the VPPS, FM & AA it was observed that the 1st floor Ambulatory Clinic area of the building was provided with skylight ceiling pockets which were not provided with sprinkler coverage to comply with NFPA 13-2010, 8.5.7 and 8.6.7.

E. On 4/12/17 at 8:55am while in the company of the VPPS, FM & AA it was observed that a sprinkler escutcheon to comply with NFPA 25-2011, 5.2.1 was missing at the 1st floor Business Office.

F. On 4/12/17 at 2:00pm while in the company of the VPPS, FM & AA it was observed that ceiling tile was missing to permit the ceiling to be open to the cavity above. The above ceiling cavity is not sprinklered. This condition does not comply with NFPA 13-2011, 8.6.4.1. Location observed include:

1. At the Basement Morgue above the cooler.
2. At the Basement Kitchen Cart Wash room.


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Based on observation during the survey walk through the facility lacks complete sprinkler protection to comply as fully sprinklered. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include

G. On 4/12/17 at 9:00 am accompanied by the FM, it was observed that the elevator machine room for Elevators 1 & 2 located adjacent to the lower level chiller room was not provided with fire sprinkler protection. This is not in compliance with NFPA 13, 2010, 8.1.

Sprinkler system components are not installed or provided in accordance with Code requirements. Failure to provide required components for maintenance of the sprinkler system can result in delayed repairs or extended periods of time without sprinkler protection.

Findings include:

On 4/12/17 at 3:50pm while in the company of the VPPS & FM it was observed that the sprinkler riser room containing the cabinet for the stock of spare sprinkler heads did not also contain a sprinkler wrench for each type of sprinkler installed at the building to comply with NFPA 13-2010, 6.2.9.6.

Based upon observation, corridor doors are not constructed to be resistant to the passage of smoke. Failure to provide corridor doors which resist the passage of smoke can compromise the use of the corridor as a means of egress for any occupants during a fire/smoke event originating within the room.

Findings include:

A. On 4/12/17 at 9:40am while in the company of the VPPS, FM & AA it was observed that the IT closets located at the 1st and Basement floors near the communicating stair of the south wing contained louvers which are not resistant to the passage of smoke to comply with 19.3.6.3.1.

B. On 4/12/17 at 2:20pm while in the company of the VPPS, FM & AA it was observed that the Kitchen Tray Return corridor doors did not have hardware to keep the doors closed and latched. The pair of doors were provided with manual flush bolts which were not engaged to secure the doors in the closed position to comply with 19.3.6.3.5.

Based upon observation and document review, smoke barrier doors are not self closing to maintain the required separation of smoke compartments. Failure to provide required separation of smoke compartments can permit fire and smoke to migrate to adjacent smoke compartments meant to provide an area of safety for occupants.

Findings include:

A. On 4/12/17 at 10:30am while in the company of the VPPS, FM & AA it was observed during the survey walk-thru and review of the facility's Life Safety reference plans that the door in the designated smoke barrier wall at the 1st floor Cardiology Alternate Exam room was not self-closing to comply with 19.3.7.8.

B. On 4/12/17 at 10:40am while in the company of the VPPS, FM & AA it was observed during the survey walk-thru and review of the facility's Life Safety reference plans that the door in the designated smoke barrier wall at the 1st floor Director of Cardiology office was not self-closing to comply with 19.3.7.8.

C. On 4/12/17 At 10:40 am while in the company of the VPPS, FM & AA it was observed during the survey walk-thru and review of the facility's Life Safety reference plans that the wall, at the 1st floor Director of Cardiology office, containing the only door to this office and the adjacent office was the designated smoke barrier wall which does not comply with 19.2.4.4.

Based on observation during the survey walk-through, not all components of the HVAC system are installed as required. This deficiency could affect patients, staff, or visitors in the building if smoke or fire was allowed to spread throughout the facility due to a missing or nonfunctioning damper.

Findings include:

On 4/12/17 at 9:39 AM, while accompanied by ET and AA at the cross corridor doors in 2 South near Room 231, in the electrical room was a large duct penetrating the floor slab. The duct did not contain a damper at the floor penetrating location. This does not meet with NFPA 90A, 2012, 5.3.

Based on document review and interview, the facility failed to conduct fire drills at varied times. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

Findings Include:

On 4/11/17, at 1:15 PM during document reviews, it was determined that the facility's quarterly fire drills do not meet the requirement of varying times for all three shifts throughout the annual cycle. Fire drills should vary a minimum of 2 hours for all four quarters on each shift. The following fire drills listed below are the shifts and quarters that are deficient based on NFPA 101, 19.7.1.6.

2nd Shift (3:00 PM to 11:00 PM)
03/30/16 at 3:34 PM
05/31/16 at 3:40 PM
08/29/16 at 8:51 PM
10/04/16 at 3:23 PM

3rd Shift (11:00 PM to 7:00 AM)
02/12/16 at 6:58 AM
06/30/16 at 6:40 AM
09/30/16 at 6:25 AM
12/04/16 at 6:25 AM

Based on staff interview during the survey walk through the facility lacks complete bonding of the electrical and medical gas piping system. Failure to install and maintain this installation could result in the piping system to become electrically energized. This deficient practice could affect patients, staff and visitors.

Findings include:

On 4/11/17 at 3:00 pm accompanied by the FM, it could not be confirmed through observation and staff interview that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with NFPA 70, 2011, 250.104 (B)

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

Findings include:

A. On 4/12/17 at 9:20am while in the company of the VPPS & FS it was observed that electrical junction boxes above the 1st floor drywall ceiling near Stair #4 lacked covers to comply with NFPA 70-2011, 314.28(C).

B. On 4/12/17 at 1:45pm while in the company of the AA & FM, a meter socket without the meter installed, labeled as 480v, was observed in the Basement Electrical Switchgear room. The contacts of the meter socket were exposed and not in compliance with NFPA 70-2011, 314.28(C).

C. On 4/12/17 at 8:55am while in the company of the VPPS & FS it was determined that on the 1st floor electrical closet near Administration, Electrical Panel "1EMLS" contained mixed electrical loads supplying both Life Safety and Critical Branch. This does not comply with NFPA 99-2012, 6.4.2.2.3.

D. On 4/12/17 at 2:55pm while in the company of the VPPS & FM it was determined that Panel "EMB" in the Basement Mechanical room contains emergency power to both Life Safety Branch and Critical Branch and does not comply with NFPA 99-2012, 6.4.2.2.

E. On 4/12/17 at 1:45pm while in the company of the VPPS, FM it was observed that required clearances at electrical distribution panels located in the Basement Bed Storage room adjacent the Elevator Equipment room was not being maintained in accordance with NFPA 70-2011, 110-34.

Based upon observation, electrical systems are not installed to prevent shock hazards. Failure to provide GFCI at specific locations can result in accidental electrical shock to users.

Findings include:

On 4/12/17 at 9:00am while in the company of the VPPS & FS it was observed that the 1st floor Administration Main Conference room Pantry was provided with an above counter receptacle within 6' of the sink that could not be verified to be GFCI protected to comply with NFPA 70-2011, 210.8(B)5.

Based on observation during the survey walk through the emergency generator installation does not comply. Failure to install and maintain this installation could result in failure of the emergency electrical system. This deficient practice could affect patients, staff and visitors during a utility failure.

Findings include:

On 4/11/17 at 2:15 pm accompanied by the FM, it was observed that the air intake plenum for the Type 1 emergency generator installation is being used for storage of miscellaneous items. This is not in compliance with NFPA 110, 2010, 7.2.

Based upon observation, medical gas cylinders are not stored separated from combustibles. Failure to separate stored oxidizing gases from combustibles can present an increased fire hazard to all occupants due to a concentrated fuel load adjacent oxidizing agents.

Findings include:

A. On 4/11/17 at 3:05pm while in the company of the VPPS, AA & FS, it was observed that multiple stored oxygen E-size cylinders were stored within 5' of combustibles not in compliance with NFPA 99-2012, 11.3.2.3. Locations observed include:

1. At the 2nd floor Respiratory Therapy equipment room where cylinders were outside the fire rated storage cabinet provided.

2. At the 2nd floor storage room where cylinders were stationed under a shelf with copy paper supply and not otherwise within a minimum 1/2-hour fire rated cabinet.

B. On 4/12/17 at 1:20pm while in the company of the VPPS, FM, FS & AA it was observed that a flammable gas cylinder (acetylene) was being stored with oxidizing gas cylinders (oxygen) within the caged manifold system for the nitrogen located at the Basement shop area as prohibited by NFPA 99-2012, 5.1.3.2.4.

1. The manifold system was also not separated from the adjacent shop area by 1-hour rated construction to comply with NFPA 99-2012, 5.1.3.3.2(4).