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Based on observation with the DPOM and the POM in attendance on 02/18/15, the surveyor finds areas open to exit access corridors do not comply with 19.3.6.1. This condition could allow fire to spread from areas open to corridor to patient exit corridors undetected.

Findings include:

1. The 6th floor ICU waiting area is open to an exit access corridor and lacks smoke detection in accordance with 19.3.6.1, exception # 1.

Based on observation with the DPOM, POM and SO present on February 17 - 19, 2015, the surveyor observed corridor doors which lack approved glazing, and corridor doors which lack positive latching hardware or hardware they have hardware which does not latch in accordance with 19.3.6.3.2. Doors were also observe which swing into the corridor. These condition could allow smoke and fire to spread beyond a room of fire origin or could result in injury to staff and patients.

Findings include:

1. At 9:15 on February 19, 2015, the surveyor observed with the DPOM present that the 2nd floor Chapel has a pair of etched glass corridor doors which lack any kind of identification on the glass identifying it as safety glazing in accordance with CPSC 16 CFR 1201 or ANSI Z97.1

2. A 6th floor Telemetry Unit has corridor auto-open sliding doors for patient rooms. The telemetry unit is identified as a diagnostic center on plan and it is not identified as a suite.

a. The sliding doors have automatic open functions from a paddle. At 10:05 AM on 02/18/15, during fire alarm testing, the provider was not able to demonstrate when and how the auto-open functions work and was not able to demonstrate that the auto-open function is disabled when the fire alarm is activated in accordance with 19.7.2.1.

b. The surveyor also observed that the sliding doors break and swing out into the required exit access corridor and do not comply with 7.2.1.4.4. When fully open in the break and swing position, they project more than 7" from the corridor wall.

Based on observation over three days, February 17-19, 2015 with the DPOM and POM in attendance, the surveyor observed that vertical openings are not protected in accordance with 8.2.5 of NFPA 101. This condition could allow fire to spread into multiple patient areas in a fire emergency.

Findings include:

1. At 2:00PM on 02/18/15 the surveyor observed a door in an abandoned dumbwaiter shaft in the 1st floor CT/MRI Waiting Room which was not self closing in accordance with NFPA 80.

2. At 2:00PM on 02/18/15 the surveyor observed a 1st floor Security Data Room with a pipe penetration through the floor which is not sealed for two hour fire rated construction.




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Based on observation during the survey walk-through, while accompanied by the Security Officer, not all vertical openings are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1 and 8.2.3.2.4. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels.

Findings include:

3. At 3:45pm on 2/18/15 it was observed in the 2nd floor hydraulic elevator 'B' machine room that ducts penetrated the floor and adjacent shaft. It appeared that fire dampers may be provided at the wall and floor duct penetrations due to screwed-on duct access panels. However, ducts through the floor had the access panels located 3'-4' above the floor which does not appear to provide access to dampers located at the floor level. Fire dampers at the floor or shaftwall were not installed in accordance with tested installation details (retaining angles) to comply with NFPA 90A-1999, 3-3.2 and NFPA 101-2000, 8.2.3.2.4.2.

Based on observation at 10:00AM on 02/18/15, during testing of the fire alarm system with the DPOM, POM and SO in attendance, the surveyor observed multiple fire doors which were held open by means which does not comply with 19.2.2.2.6 and 7.2.1.8. Failure to close fire doors could result in the spread of fire and smoke beyond the location of fire origin.

Findings include:

1. The pair of fire doors in the designated one hour north wall of the Service Building do not close from activation of smoke detection installed within five feet of the doors (no smoke detectors are installed) and from activation of the sprinkler system which protects each side of the doors.

2. A pair of fire doors in the designated four hour fire wall between the Main Hospital and the receiving area are held open by means not complying with 7.2.1.8.. These fire doors lack smoke detection installed within five feet of the doors and they did not close automatically from activation of the sprinkler system which protects each side of the doors.

3. The pair of fire rated doors to the maintenance shop did not close from activation of smoke detection installed within five feet of the doors (no smoke detectors are installed) and from activation of the sprinkler system which protects each side of the doors in accordance with 19.2.2.2.6 and 7.2.1.8.


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4. At 3:30pm on 2/18/15 it was observed that the 2nd floor PT Suite Storage room door was a labeled self-closing fire rated door with a foot peg hold-open device not in compliance with 7.2.1.8.2.

Based on observation on February 17 - February 19, 2015, with the DPOM and the POM present, the surveyor observed hazardous areas which are not enclosed in accordance with 19.3.2.1. This condition could allow fire to spread beyond the areas with high fuel loads into patient areas and corridors.

Findings include:

1. The 4th floor surgical suite has a large volume of storage in the corner aisle near Operating Room # 1. The total storage is in excess of 100 Square feet and a one hour fire rated enclosure is not provided.

2. A 3rd floor pediatric storage space has a pair of fire rated doors which are not self closing in accordance with 19.3.2.1 and NFPA 80.

3. A 3rd floor dialysis storage room has a fire rated door which is not self closing.

4. The radiology south aisle has a barrel of film (highly combustible) left in the aisle. The container was not stored in a one hour fire rated enclosure.

5. The 8th floor has an access panel into a very large attic space to the east. This attic space is used as a mechanical space. A two hour fire barrier is identified on Life Safety Plans between the 8th floor corridor and the attic. The attic has been evaluated as a hazardous area. The hatch in the wall between the 8th floor corridor and the attic is not self closing.

7. A 6th floor storage room (Room 614) lacks a 3/4 hour fire rated door.

8. The 2nd floor Outpatient Pharmacy is not separated from the adjacent corridor by smoke tight construction in accordance with 8.4.1.2. It is located on a floor with no -inpatient sleeping or treatment. the floor is mixed use, storage. business, assembly in a health care build. The outpatient pharmacy was renovated approximately in 2006 and is a hazardous area under 38.3.2.1 and 12.3.2.1.3.

Based on observation during the survey walk-through, while accompanied by the Security Officer, not all hazardous areas are separated from the remainder of the building in accordance with 39.3.2.1 and 8.4.1. 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 the building's exit access paths.

Findings include:
1. At 1:00pm on 2/18/15 it was observed that the building furnace room containing gas fired appliances was not sprinklered or otherwise separated by 1-hour construction to comply with 39.3.2.1, 8.4.1, 8.2.3.2.1 and NFPA 80. Walls & penetrations were not protected and the room lacked a minimum 3/4-hour fire rated door assembly.

Based on observation during the survey walk-through, while accompanied by the Security Officer, the surveyor found that the not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1, 39.3.2.1 and 8.4.1. These deficiencies could affect all staff and visitors present, as well as patients within the building by allowing smoke and fire to compromise exit access within building.

Findings include:
1. At 1:40pm on 2/17/15 it was observed that the 4th floor corridor accessing the On-Call rooms in the unsprinklered portion of the building was being used to store 15 garbage bags full of used clothing. A closet (former phone booth room) at this location was also being used as a "bin" for used clothing. The requirements of 19.3.2.1, 19.7.5.5, 39.3.2.1 and 8.4.1 are not met because the quantity and density of used clothing is deemed to be a hazard greater than that normal to the general occupancy and is not separated by 1-hour construction or stored separately in an area protected by automatic sprinkler system.

2. At 2:45pm on 2/17/15 it was observed that the 3rd floor Storage room 310 was not sprinklered and not separated by 1-hour rated construction including a minimum 3/4-hour rated self-closing door assembly to comply with 39.3.2.1 and 8.4.1.

Based on observation during the survey walk-through, while accompanied by the Security Officer, exits are not provided in accordance with 38.2.4. Failure to provide required exits can compromise the safety of all occupants relying on exits to reach safety.

Findings Include:
1. At 2:15pm on 2/18/15 it was observed that the Little Village facility has a second floor area which is currently unoccupied as part of the business function, but the fire alarm panel and electrical panels are located at this level. It is used only for minor general storage. Although this floor area is described as a mezzanine, it does not comply with NFPA 101-2000, 8.2.6 as a mezzanine because it is not open to the floor area below to comply with 8.2.6.3 and the area is not otherwise provided with at least two means of egress with not less than one means of egress providing direct access to an exit at the floor area level to comply with the exception to 8.2.6.3. The travel distance from the farthest point to the stair appeared to exceed the 100' distance permitted by any of the 38.2.4.2 exceptions. The stair provided as the only exit is not enclosed at the ground floor level to comply with 7.2.2.5.

Based on observation on February 17, 18 and 19, 2015, with the DPOM and POM present, the surveyor finds that two required exit stairs do not comply with provisions of Chapter 7 of NFPA 101. the use of exit enclosures for systems which are not permitted in the exit could compromise the use the exit in an emergency.

Findings include:

1. Two required exit stair enclosures are used for purposes or have systems which do not serve only the exit. The recent installation of data boxes and data systems conduit in one or more exit stairs of the main hospital does not comply with 7.1.3.2.1. Locations include:

a. South/center exit stair

b. 6 west exit stair

Based on observation on February 17-19, 2015, with the DPOM and POM present, the surveyor find that multiple required exit stairs do not comply with provisions of Chapter 7 of NFPA 101.

Findings include:
1. The east middle exit stair enclosures was used for purposes or have systems which do not serve only the exit and do not comply with 7.1.3.2.1. This includes the none-fire-rated hatch (access to mechanical spaces below) in the 1st Floor landing of the middle annex exit stair.

a) The hatch does not latch without manual help.

b ) The hatch is not B label opening protective.

c) The hatch is not permitted in an exit stair.

2. The required middle annex exit stair has handrails on the interior side of the stair and not on both side of the stairs in accordance with 7.2.2.4.2.

3. 1st Floor, the exit passageway from the middle annex stair has three doors. One has a continuous hinge which is listed for a 1 1/2 hour door; however there is no UL label on the door.

A. Based on observation on February 17-19, 2015, with the DPOM and POM present, the surveyor observed multiple exit stairs have an exit discharge to the outside which are obstructed enough to render them unusable or hazardous as an exit discharge. A safe and unobstructed path to a public way was not provided in the event of an emergency accordance with 7.7 of NFPA 101. These conditions will delay patient evacuation in an emergency.

Findings include:

1. The exit discharge into the area between the Main Building and the Service Building was covered with a thick layer of Ice and snow. This discharge path served as the exit discharge for a require exit stair serving multiple patient floors and as the exit discharge for a 1st floor exit access corridor.

2. The Main Building northwest exit stair serves multiple patient floors. It discharges to the north into the ambulance bay, under an exterior canopy. The path directly to the north has a concrete wheel stop which is a tripping hazard. No barriers or warnings are installed. The intended path to the east was obstructed by snow and a wall mounted steel shelf (about head high).

B. Based on observation on February 17-19, 2015, with the DPOM and POM present, the surveyor observed that exit paths are locked or obstructed and dead-end conditions in excess of thirty feet exist which do not comply with 7.2.1.6.1 and/or 19.2.5.10. This condition will delay patient evacuation in an emergency.

Findings include

1. The back exit access corridor in the 1st floor Imaging Department is not identified as part of a suite. The back aisle is continuous lined with equipment which obstructs the the aisle to less than 44" in clear width. A door to the outside is marked as an exit; however, the 1st step is 16" in height; this step does not comply with 7.2.2.1(a). This creates a dead-end condition in excess of 70'.

2. The 7th floor exit access corridor to the east has a 40' dead-end condition. This portion of the corridor has access to only one exit. The door to the east enters a psychiatric unit and is locked against entry. This corridor does not comply with 7.5.1.6, 19.2.5.10, and 19.2.4.

3. The 5th floor Mother/Baby Unit has an electronically locked door that does not comply with 7.2.1.6.1.

a. The door lacks a sign in accordance with 7.2.1.6.1 (d).

b. The door lacks an audible alarm in accordance with 7.2.1.6.1 (c).

c. The door has a lever latch-set which requires special knowledge to operate and release the door lock. The door is not a push and release device in compliance with 7.2.1.5.1.

6. Room 464 on a psychiatric floor was observed with the DPOM and SO present with a locked bathroom door. The provider was not able to unlock this door. This locked doors does not comply with providers written procedures for locked doors in a psychiatric unit.

7. The locked door in the corridor between the 6th floor ICU and the Diagnostic Center creates a 40' dead-end corridor.


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Based on observation during the survey walk-through, while accompanied by the Security Officer, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1, and Chapter 7. These deficiencies could affect all staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:
8. At 10:15am on 2/18/15 it was observed that the 1st floor cross corridor doors marked as an available exit from the Ambulance Entrance Elevator 'B' Lobby was equipped with a dead bolt lock in addition to latching hardware which can require two releasing operations to open the doors in non-compliance with 7.2.1.5.4.

Based on observation during the survey walk-through, while accompanied by the Security Officer, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1, 39.2.1.1 and Chapter 7. These deficiencies could affect all staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:
1. At 2:30pm on 2/17/15 the 3rd floor pharmacy inner door was observed to be an outswinging dutch door which is equipped with a lockset on the lower leaf and a dead bolt lock to the frame on the upper leaf. A slide bolt is also provided to engage the top leaf with the bottom leaf. The hardware arrangement does not comply with 7.2.1.5.4 because the top and bottom leafs can be secured independently from each other and prevent opening of the door with a single releasing operation. The bottom leaf is not provided with a device to swing the top leaf when the bottom leaf is unlatched and opened for the purpose of egress.

2. At 1:45pm on 2/17/15 it was observed on the 4th floor and also 2:30 on 3rd floor and 3:10pm on the 2nd floor that the north annex stair is considered to be a communicating stair and not an exit stair. However, exit signs are provided in the corridors of the Annex outside the stair to indicate a required exit path toward the communicating stair, but signage on the stair door reads "Not an Emergency Exit". No signage is provided at the communicating stair door to indicate that the exit path is through the stair to access the main hospital northwest exit stair to comply with 39.2.10 & 7.10.1.4. The doors on the main hospital side of the communicating stair swing into the stair and not in the direction of exit travel from the Annex toward the northwest stair of the main hospital to comply with 7.2.1.4.2.

Based on document review of Life Safety Plans date 09/06/13, based on personnel interview on 2/17/15 with the DPOM, POM, and SO and based on the survey walk-thru on 2/18/15, the surveyor find that building separations and two hour fire barriers (or greater) 8.2.2 and 8.2.3 are not provided in accordance with 18.3.7.1 through 18.3.7.7.
Failure to provide and maintain fire compartmentalization where required will limit where patients can be evacuated to in case of an emergency.

Findings include:

1. The two hour fire barrier identified on the Life Safety Plans date 09/06/13 at the east end of the 1st floor corridor is not constructed to be a two hour fire barrier.

2. The four hour fire barrier identified on the Life Safety Plans date 09/06/13 at the 1st floor south side of the hospital (separates the hospital from the Service building) is required to be at least a two hour fire barrier in accordance 19.1.1.4.1. The window openings in the south wall, containing window air conditioners, is not constructed to comply with 8.2.3 as a two hour fire barrier.

Based on observation during the survey walk-through, while accompanied by the Security Officer, not all designated or required fire barriers are maintained as fire resistive assemblies in accordance with 19.2.2.5. and 8.2.3.2. Failure to maintain fire barriers can compromise the intended function of providing protective features of the building for occupant safety during a fire emergency.

Findings include:
At 2:00pm on 2/17/15 it was observed that the 4th floor 2-hour barrier which was identified as separating the sprinklered portion of the Annex building from the non-sprinklered was not constructed to provide a 2-hour rated assembly. The plaster ceiling has been removed at the Mechanical room adjacent the Center Exit Stair and the wall was not full height to the bottom of the roof deck to provide complete separation of the Stair in accordance with 7.1.3.2.1(b). Piping from the Mechanical room which penetrated the 2-hour barrier wall as observed above the lay-in ceiling in the Men's Toilet room to lack protection in accordance with 8.2.3.2.4.2.

Based on observation and staff interview during the survey walk-through, while accompanied by the Security Officer, exit discharge locations are not provided with illumination to comply with 38.2.8, 38.2.9, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:
1. At 2:00pm on 2/18/15 it was observed that the lighting provided at the east exterior exit doors and the access to the public way were HID type and not of the instant-on type (incandescent, fluorescent, quartz or LED) to provide lighting of the means of egress in accordance with 7.8.1.2 and 7.8.1.4. This lighting was also not provided with an alternate power source to provide emergency lighting in accordance with 38.2.9.1 and 7.9.

Based on observation and staff interview during the survey walk-through, while accompanied by the Security Officer, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:
1. At 3:00pm on 2/18/15 it was observed that the lighting provided at the east stair exterior exit door and the access to the public way were HID type and not of the instant-on type (incandescent, fluorescent, quartz or LED) to provide lighting of the means of egress in accordance with 7.8.1.2 and 7.8.1.4.

Based on observation during the survey walk-through, while accompanied by the Security Officer, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1, 39.2.10 and 7.10. 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:
1. At 3:15pm on 2/18/15 it was observed that exit signage is provided at the 2nd floor medical staff office which directs an exit path through the medical records storage area (hazardous area) is non-compliant with 7.5.1.7.

Based on the review of fire drill documentation for the previous twelve months and based on interview of the SO, the surveyor finds that fire drills are not always conducted in accordance with 19.7.1.2. Failure to close all doors, including any which area by passed during a fire emergency will allow fire and smoke to spread beyond the location of fire origin.


Findings include:

On 02/17/15 in the morning, the surveyor observed that the door functions, particularly smoke door functions, are by-passed routinely on fire drills (3/5/14, 3/19/14, 5/6/14, 7/31/14, 11/28/14 for example). However the provider does not observe and document on fire drills that staff will close all doors which are by-passed in accordance with the written fire plan and 19.2.7.2.

Based on the review of documentation with the DPOM and SO and based on the interview of the SO, the surveyor finds that fire drills are not always conducted in accordance with 19.7.1.2. Failure to close all doors, including any which area by passed during a fire emergency will allow fire and smoke to spread beyond the location of fire origin.


Findings include:

On 02/17/15 in the morning, the surveyor observed that the door functions and particularly smoke door functions are by-passed routinely on fire drills (3/5/14, 3/19/14, 5/6/14, 7/31/14, 11/28/14 for example). However, the provider does not observe and document on the fire drills that staff will close all doors which are by-passed in accordance with their written fire plan and 19.2.7.2.

Based on observation during the survey walk through, while accompanied by the Security Officer, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA 72-1999. This could affect all occupants of the building if the fire alarm system does not operate properly during a fire emergency.

Findings include:
1. At 2:30pm on 2/18/15 it was observed that the fire alarm system did not comply with all requirements of NFPA 72-1999, 1-5.2.5.2. The fire alarm control panel was not labeled to identify the electrical circuit and panel from which it is fed and the electrical panel circuit feeding the fire alarm control panel did not include a lock-on device.

Based on observation during the survey walk through while accompanied by the Security Officer, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA 72-1999. This could affect all occupants of the building if the fire alarm system does not operate properly during a fire emergency.

Findings include:
1. At 1:30pm on 2/17/15 it was observed that the smoke detector located in the south Elevator Penthouse (accessed from the roof) was not mounted at the ceiling junction box. The detector was hanging from wires 12" or more from the ceiling surface and not in compliance with NFPA 72-1999, 2-3.4.3.1.

Based on observation during the survey walk through, while accompanied by the Security Officer, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA 72-1999. This could affect all occupants of the building if the fire alarm system does not operate properly during a fire emergency.

Findings include:
1. At 3:20pm on 2/18/15 it was observed that the smoke detector located in the janitor room adjacent the Financial Counselor office was not mounted at the ceiling surface in noncompliance with NFPA 72-1999, 2-3.4.3.1.

The following deficient practice will allow products of combustion to move from compartment to compartment.

1. At 9:45 a.m. 2/18/15 on the 3rd Floor during fire alarm testing while in the company of the Patient Experience Manager, the cross corridor fire doors by Room 333, did not close to a latched position due to the door coordinator malfunction.

2. At 10:00 a.m. 2/18/15 on the 1st Floor during fire alarm testing while in the company of the Patient Experience Manager, the cross corridor fire doors by the Cafeteria Vending Machine Room did not close to a latched position due to one door caught on the door wall pocket.

Based on observation on February 16, 2015, during the survey walk-thru accompanied by the DPOM and POM, the surveyor observe that the 1st Floor Emergency Department is contained within a required fully sprinkler fire compartment/smoke compartment. This sprinkler system is not installed and maintained in accordance with NFPA 13 - 1999. Any fire in this stair will not be controlled by a sprinkler head at the bottom of the stair.

Findings include:

1st Floor landing at the bottom of the Annex Middle Exit stair lacks sprinkler protection in accordance with NFPA 13.


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The following deficient practice will delay the extinguishment of a fire.

1. At 11:00 a.m. 2/17/2015 on the 4th floor while in the company of a Plant Operation engineer and Security Officer, the surveyor finds by direct observation the ceiling open and unfinished in the sterilizer equipment room. This deficient practice compromises the sprinkler fire protection.

Based on direct observation on February 17-19, 2015, with the DPOM and the POM present, the surveyor finds the sprinkler protection is not installed and maintained in accordance with NFPA 13 -1999. The provider has identified the Main Hospital as fully sprinklered. Based on recent renovation projects, based on the building height (8 story high rise) and based on 11.8.2 and 19.3.5 of NFPA 101 - 2000, a sprinkler system is required. Failure to install and maintain a sprinkler system could result in spread of fire, uncontrolled to multiple patient areas

Findings Include:

1. The main entrance drop off canopy which serves as the emergency room entrance, the exit discharge for a 1st floor exit path and an eight story patient exit stair, lacks sprinkler protection in accordance with NFPA 13, 4-13.7. The main entrance drop off canopy and ambulance bay is an unprotected steel structure which is attached to the hospital. Vehicles including cars, police vehicles and emergency vehicles are routinely parked under this canopy and are left unattended.

2. The following locations lacks sprinkler protection and do not comply with the exceptions for unsprinklered spaces.

a. 8th floor convenience stair - bell rope closet inside this stair lacks sprinkler protection.

b. Multiple elevator machine rooms (all elevator machine rooms except for the hydraulic machine rooms) lack sprinkler protection. See K160.

c. 6 south/center exit stair - the sprinkler pressure gauge was not functioning.

d. Laundry chute closet on multiple floors (except 7) lacks sprinkler protection.

e. 6th floor ICU staff work room - the deep niche for purses is not sprinklered.

f. 1st floor pop closet is not sprinklered.

g. 1st floor dish washing room has two of two sprinkler heads which were corroded and covered with grime. The surveyor observed that the above heads had been cleaned by the morning of 2/19/15. The DPOM was not able to identify how the heads were cleaned and why replacement is not required under NFPA 13.

h. 1st floor security video surveillance room is not sprinklered and lacks a smoke tight ceiling (room is open to ceiling cavity above).

i. The sprinkler system above the rolling files in the medical records room is obstructed and not installed in accordance with NFPA 13.

j. The space under a stair in the 1st floor kitchen lacks sprinkler protection.

k. 2nd floor outpatient pharmacy has one shelf with storage which obstructs the sprinkler system.

l. 1st floor laundry chute discharge room is open to the laundry chute vertical shaft. It lacks a draft stop around the laundry chute as a barrier for the sprinkler protection in this room.


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3. At 3:00pm on 2/18/15 it was observed that a ceiling tile had been removed at the chapel storage room to accommodate poles for vertical storage in the corner. Removal of the ceiling tile can compromise the response of sprinklers intended to be installed in accordance with NFPA 13-1999, 5-6.4.1.

4. At 3:05pm on 2/18/15 it was observed that sprinkler heads were not installed below ductwork 4' or wider in the Chapel Mechanical room in compliance with NFPA 13-1999, 5-6.5.3.1.



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5. At 2:15 p.m. 2/17/2015 on the 2nd floor while in the company of a Plant Operation Manager, the surveyor finds the Data Closet located in the mechanical room adjacent to the Chapel does not have a fire suppression system installed.

6. At 2:30 p.m. 2/17/2015 on the 1st floor kitchen while in the company of a Plant Operation Manager, the surveyor finds that all walk-in coolers and freezers are not provided with fire sprinkler protection.

The provider has identified the Service Building as fully sprinklered. Based on observation the surveyors , with the DPOM and the POM attending on February 18, 2015, find that sprinkler protection is not always installed and maintained in accordance with NFPA 13 -1999. Failure to install and maintain a sprinkler could result in spread of fire, uncontrolled to multiple patient areas.

Findings include:
1. The three story Service Building lacks an inspector's test valve which is installed to simulate the flow of one sprinkler head and which is identified with a sign. This condition was also not found and abated during quarterly or annual inspection, testing and maintenance in accordance with NFPA 25 - 1998.

Based on observation during the survey walk-through, while accompanied by the Security Officer, sprinkler systems are not installed in accordance with NFPA 13-1999. Failure to maintain the installation conditions can result in delayed response to a fire condition the sprinkler system is designed to control.

Findings include:
1. At 2:15pm on 2/18/15 it was observed that a portion of the 2nd floor area that was originally installed with lay-in ceiling system and pendant sprinkler heads had the ceiling system partially removed without the heads being re-oriented to comply with NFPA 13-1999, 5-6.4.1

Based on observation, document review and interview of the DPOM, the surveyor find the receiving corridor between the Main Hospital and the Service Building has a sprinkler system which is identified by the DPOM as an anti-freeze loop. The surveyor find that this sprinkler system in this building is not maintained in accordance with NFPA 25 - 1998. Failure to test and maintain the system could allow it to freeze and fail in a fire emergency.


Findings include:

1. Based on an interview with the DPOM on the morning of 02/17/15, the surveyor finds that there is no documentation for annual testing, service and maintenance of this anti-freeze loop system in accordance with NFPA 13 and NFPA 25. No one is testing for specific gravity, low point temperature and/or FDA approved chemical requirements.

Based on record document review, while accompanied by the Security Officer, sprinkler systems are not maintained in accordance with NFPA 13 & 25. Failure to maintain the installed sprinkler system can compromise the safety of occupants in the event of fire.

Findings include:
1. At 8:30am on 2/19/15 during document review of the sprinkler system inspection records for the Little Village Clinic, the documentation stated: "Note: Portion of Mega Mall buildings St. Anthony's space being tested by their own contractor as per Manager of St. Anthony." No other documentation of inspection and testing of the sprinkler system was available to indicate that the St. Anthony tenant space portion of the building was being tested/inspected to comply with NFPA 25-1998, Chapter 2.

Based on observation during the survey walk through while accompanied by the Facility Electrician, the surveyor found that the fire pump installation did not meet all of the requirements of NFPA-20. This could affect all occupants of the building if the fire pump does not operate during fire emergency.

Findings include:
1. The fire pump was not equipped with the four required alarm points as required by NFPA-20, Section 7-4.7: a) loss of phase, b) pump running, c) phase reversal, and d) connected to emergency source of power.

2. On Wednesday, February 18, 2015 at approximately 10:50 AM the surveyor observed that the fire pump was not served by the emergency generator.

Based on an inspection of the 1st floor kitchen with the DPOM and the POM on the morning of February 19, 2015, the surveyor finds cooking systems which are not installed and maintained in accordance with NFPA 17/17A and NFPA 96. This condition could result in a serious and uncontrolled fire in the Kitchen exhaust duct system.

Findings include:

1. The kitchen exhaust (grease) duct has multiple access panels above the ceiling in the 1st Floor kitchen which are not fire rated access panels for a grease ducts in accordance with NFPA 96

2. The main cooking line has two gas fryers which are not being used but are not disconnected from the gas line. The filter bank above the fryers has a gap which will allow any grease to bypass the grease filters.

3. No access panel for cleaning was found above the ceiling of the 1st floor kitchen for the east end of the kitchen exhaust duct where the duct changes direction from horizontal to vertical, in accordance with NFPA 96.

4. There is an electrical junction box anchored to the kitchen exhaust ducts above the ceiling in the 1st Floor kitchen, in front of the gas range. Any screw penetrations of the exhaust duct constitute a violation of NFPA 96.

5. The DPOM indicates that the hood suppression system is a dry chemical system. This system can comply with NFPA 17 but not NFPA 17A. A dry chemical system cannot comply with UL 300. The annual documentation for testing and maintenance of this hood suppression system fails to identify this system as not in compliance with UL 300. The documentation also fails to identify the system deficiencies identified under Item 1 - 5 above.

Based on observation with DPOM and the POM present, the surveyor finds that medical gas systems do not comply with NFPA 99 and/or NFPA 50. This could delay staff response in an emergency with the medical gas system.


Findings include:

1. Based on observation on the afternoon of 2/18/15, with the DPOM present, the surveyor observed a medical gas alarm panel on the 1st floor MRI corridor wall that lacked identification in accordance with NFPA 99 - 1999.


2. Based on observation on the afternoon of 2/17/15, with the DPOM present, the surveyor observed a hospital bulk oxygen system is located immediately adjacent to storage containers and two a parking area. Combustible storage is not maintained at least 25' from the bulk oxygen tanks in accordance with NFPA 50 and there are no barriers to restrict parking to no closer than 10'.

Based on observation during the survey walk through while accompanied by the Facility Electrician, the surveyor found that the generator installation did not meet all of the requirements of NFPA 110-1999. This could affect all occupants of the building if the generator does not operate during the loss of normal power.

Findings include:
1. On Wednesday, February 18, 2015 at approximately 11:00 AM the surveyor observed that the 50 kW and 200 kW generators were not equipped with remote manual stop stations in accordance with NFPA-110, Section 3-5.5.6.

2. On Wednesday, February 18, 2015 at approximately 11:05 AM the surveyor observed that the facility's remote annunciators were not located at a location that was staffed 24/7 as required by NFPA 99-1999, Section 3-4.1.1.15. The plant office is not considered 24 hour since plant personnel are often working out in the plant.

3. On Wednesday, February 18, 2015 at approximately 11:10 AM the surveyor observed that the battery charger was connected directly at the battery terminals which is not allowed by the 1999 Edition of NFPA-110, Section 5-12.6.

Based on observation during the survey walk-through, February 17 through 19, 2015, and based on document review, and staff interview, with the DPOM, POM and SO the surveyors find the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

Findings include:

A. 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 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 interim life safety measures to remain in place as work toward the completion of its PoC progresses.

.




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The following deficient practice allows for ventilation air to be circulated from the mechanical room not the outdoors as required.

B. At 2:00 p.m. 2/17/2015 on the 3rd floor while in the company of a Plant Operation Engineer, the surveyor finds AHU S3B outdoor air intake plenum open to the mechanical room. This deficient practice allows for ventilation air to be circulated from the mechanical room not the outdoors as required. AHU S3B is also the outside air source for the Compressed Patient Medical Air for the facility.

Based on observation during the survey walk-through, document review, and staff interview, with the DPOM, POM and SO the surveyors find the facility is not in compliance with the Life Safety Code and other code requirements that are documented under the K-Tags of this survey.

Findings include:
A. 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 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 interim life safety measures to remain in place as work toward the completion of its PoC progresses.

.

Based on observation with the DPOM and the POM, the surveyor observed the electrical systems and materials are not installed and maintained in accordance with NFPA 70-1999. This will delay any response in an electrical emergency, forcing removal of the stored items to get to the panels; it could cause a fire if electrical circuits cannot be turned off quickly.

Findings include:


1. At the 1st floor receiving room south of the main hospital and at the north side of the Service Building on 02/17/15 and the morning of 2/18/15 the surveyor observed multiple wall mounted electrical panels where stored items and received materials are routinely parked in front of the panels. The 3' of clear space in front of the panels are not maintained in accordance with NFPA 70.

Based on observation, with the DPOM present on February 17-19, 2015, the surveyor finds that electrical systems and materials are not installed and maintained in accordance with NFPA 70 1999. Failure to install and maintain electrical systems could result in a fire.

Findings include:

1. At 9:00AM on 02/18/15, the surveyor observed a "gravel roof storage room" with multiple electrical extension cords in permanent use.

2. At 4:05 PM on 02/17/15, the surveyor observed a 4th floor scope re-processing room with an orange extension cord in permanent use.

3. At 4:05 PM on 02/17/15, the surveyor observed in the 4th floor scope re-processing room that access to a wall mounted electrical panel is blocked by storage. The 3' of clear space in front of the panel is not maintained in accordance with NFPA 70.

4. At 1:10PM on 02/18/15, the surveyors observed a 3rd floor nurse station with an orange extension cord in permanent use.

5. At 1:00AM on 02/18/15, the surveyor observed that the surgical HVAC room has an open electrical junction box which lacks a cover.

6. At 2:15PM on 02/18/15, the surveyor observed in the MRI equipment room at back of MRI control room, that access to two electrical panels is blocked by storage. The 3' of clear space in front of each panel is not maintained in accordance with NFPA 70.

7. At 3:15PM on 02/18/15, the surveyor observed in the 1st floor security data closet, that access to electrical panels was blocked by a table and a ladder. The 3' of clear space in front of the panel is not maintained in accordance with NFPA 70. The electrical panel lacks circuit identification for every electrical circuit including spares.

8. At 3:00PM on 02/18/15, the surveyor observed in the 1st floor dishwashing room, that access to the electrical panel is blocked by permanently installed equipment. The 3' of clear space in front of the panel is not maintained in accordance with NFPA 70.



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Based on observation during the survey walk through while accompanied by the Facility Electrician,the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

9. On Tuesday, February 17, 2015 at approximately 2:00 PM the surveyor observed that the elevator cab lights in elevators B, C, D, E, and F were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32, and the elevators were not equipped with cab lighting disconnects in the elevator equipment rooms in accordance with NFPA-70, Section 620-53.

10. On Wednesday, February 18, 2015 at approximately 10:30 AM the surveyor observed that the hospital ICU rooms, C-Section room, Operating Rooms, Stage 1 recovery rooms, and labor and delivery room 506 were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-19. This could effect all patients in this area if the transfer switch failed and no normal or emergency power was available at the bed locations.

11. On Tuesday, February 17, 2015 at approximately 2:30 PM the surveyor observed that the med/surg rooms, and the Mother/Baby rooms were not equipped with critical power receptacles to meet the requirements of NFPA-70, Section 517-18.

12. On Wednesday, February 18, 2015 at approximately 10:30 AM the surveyor observed that the emergency receptacles were not labeled in all critical care areas such as the ICU rooms, labor and delivery rooms, and Operating Rooms in accordance with NFPA-70, section 517-19.

Based on observation during the survey walk-through, while accompanied by the Security Officer, not all portions of the facility's electrical distribution system are in accordance with NFPA 70-1999. Failure to maintain the electrical system can result in a shock hazard or disruption of the electrical system.

Findings include:
1. At 1:40pm on 2/17/15 it was observed that an electrical junction box at the top of Stair #5 (South Stair) lacked a cover to enclose the wiring connections within the conduit system to comply with NFPA 70-1999, 370-25.

2. At 2:00pm on 2/17/15 it was observed at the 4th floor outside the Mechanical room adjacent the center stair that open junction boxes existed above the ceiling in noncompliance with NFPA 70-1999, 370-25. It was not verified that these were abandoned, non-functional electrical systems.

Based on direct observation on February 17-19, 2015, with the DPOM, POM and SO present, the surveyor find that the elevators and elevator machine rooms do not comply with 9.4.6 of NFPA 101 along with ANSI A17.3 (National Elevator Code).

Findings include:

1. Documentation and certifications of elevator fire department recall, in accordance with ANSI A17.3 was requested during the initial entrance interview at 8:30AM on February 17, 2015. Although the provider has documentation, the documentation did not demonstrate fire department recall, to primary and alternate floors, for every elevator in accordance with ANSI A17.3.

a. The annual testing and maintenance documentation did not clearly identify every floor and every elevator. The documentation did not certify testing conducted in accordance with ANSI A17.3.

b. According to the DPOM monthly testing of fire department elevator recall is not conducted in accordance with ANSI A17.3.



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Based on observation during the survey walk-through, while accompanied by the Security Officer, Elevators are not provided with elevator recall in accordance with ASME/ANSI A17.3 and 19.5.3, 39.5.3, and 9.4.3.2. Failure to maintain firefighter and recall operation of the elevators can compromise occupant safety & escape and prevent firefighter use in accessing fire locations.

1. At 2:50pm on 2/17/15 it was observed that the south elevator of the Annex building was identified by staff to be non-operational. It was not clearly evident that this elevator was equipped with elevator recall or clearly identified to occupants as being out of service.

The above elevator and the electrical equipment in the elevator machine room were not tagged out in accordance withe NFPA 70 to indicate that the equipments was not functioning.

Based on direct observation on all three days of the survey, February 17-19, 2015, with the DPOM, POM, and SO present, the surveyors find that the elevators and elevator machine rooms do not comply with 9.4.6 of NFPA 101 along with ANSI A17.3 (National Elevator Code).

Findings include:

1. Documentation and certifications of elevator fire department recall, in accordance with ANSI A17.3 was requested during the entrance interview at 8:30AM on February 17, 2015. The documentation presented by the provider did not demonstrate annual testing of fire department recall, to primary and alternate floors, for every elevator in accordance with ANSI A17.3.

a. The annual testing and maintenance documentation did not clearly identify every floor and every elevator. The documentation did not certified testing conducted in accordance with ANSI A17.3.

b. According to the DPOM monthly testing of fire department elevator recall is not conducted in accordance with ANSI A17.3.

c. Although the hydraulic elevator machine room for Elevator B has sprinkler protection, one of two sprinkler heads lacks a heat detector installed within two feet of each head. There is no evidence of a shunt trip to shut down the elevators before activation of sprinkler protection for Elevator B and/or for five of five elevators. The use of the Elevator B machine room for storage, particularly combustible storage does not comply with ANSI A17.3.

d. During fire alarm testing on 02/18/15 at 10:00AM, the surveyor observed that one of the elevators recalled to the 1st floor which a sprinkler flow switch was tested. This elevator had to be reset once the fire alarm was reset. The DPOM indicated that all elevators automatically recall (fire department recall) any time any sprinkler flow switch activates in the building activates. based on this the surveyors find automatic fire department recall is not limited to only the activation of elevator Lobby smoke detection and from smoke detection in elevator machine rooms, in accordance ANSI A17.3, 2.27.3.2.

Based on observation with the DPOM and the POM in attendance on 02/18/15, the surveyor finds areas open to exit access corridors do not comply with 19.3.6.1. This condition could allow fire to spread from areas open to corridor to patient exit corridors undetected.

Findings include:

1. The 6th floor ICU waiting area is open to an exit access corridor and lacks smoke detection in accordance with 19.3.6.1, exception # 1.

Based on observation with the DPOM, POM and SO present on February 17 - 19, 2015, the surveyor observed corridor doors which lack approved glazing, and corridor doors which lack positive latching hardware or hardware they have hardware which does not latch in accordance with 19.3.6.3.2. Doors were also observe which swing into the corridor. These condition could allow smoke and fire to spread beyond a room of fire origin or could result in injury to staff and patients.

Findings include:

1. At 9:15 on February 19, 2015, the surveyor observed with the DPOM present that the 2nd floor Chapel has a pair of etched glass corridor doors which lack any kind of identification on the glass identifying it as safety glazing in accordance with CPSC 16 CFR 1201 or ANSI Z97.1

2. A 6th floor Telemetry Unit has corridor auto-open sliding doors for patient rooms. The telemetry unit is identified as a diagnostic center on plan and it is not identified as a suite.

a. The sliding doors have automatic open functions from a paddle. At 10:05 AM on 02/18/15, during fire alarm testing, the provider was not able to demonstrate when and how the auto-open functions work and was not able to demonstrate that the auto-open function is disabled when the fire alarm is activated in accordance with 19.7.2.1.

b. The surveyor also observed that the sliding doors break and swing out into the required exit access corridor and do not comply with 7.2.1.4.4. When fully open in the break and swing position, they project more than 7" from the corridor wall.

Based on observation over three days, February 17-19, 2015 with the DPOM and POM in attendance, the surveyor observed that vertical openings are not protected in accordance with 8.2.5 of NFPA 101. This condition could allow fire to spread into multiple patient areas in a fire emergency.

Findings include:

1. At 2:00PM on 02/18/15 the surveyor observed a door in an abandoned dumbwaiter shaft in the 1st floor CT/MRI Waiting Room which was not self closing in accordance with NFPA 80.

2. At 2:00PM on 02/18/15 the surveyor observed a 1st floor Security Data Room with a pipe penetration through the floor which is not sealed for two hour fire rated construction.




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Based on observation during the survey walk-through, while accompanied by the Security Officer, not all vertical openings are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1 and 8.2.3.2.4. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels.

Findings include:

3. At 3:45pm on 2/18/15 it was observed in the 2nd floor hydraulic elevator 'B' machine room that ducts penetrated the floor and adjacent shaft. It appeared that fire dampers may be provided at the wall and floor duct penetrations due to screwed-on duct access panels. However, ducts through the floor had the access panels located 3'-4' above the floor which does not appear to provide access to dampers located at the floor level. Fire dampers at the floor or shaftwall were not installed in accordance with tested installation details (retaining angles) to comply with NFPA 90A-1999, 3-3.2 and NFPA 101-2000, 8.2.3.2.4.2.

Based on observation at 10:00AM on 02/18/15, during testing of the fire alarm system with the DPOM, POM and SO in attendance, the surveyor observed multiple fire doors which were held open by means which does not comply with 19.2.2.2.6 and 7.2.1.8. Failure to close fire doors could result in the spread of fire and smoke beyond the location of fire origin.

Findings include:

1. The pair of fire doors in the designated one hour north wall of the Service Building do not close from activation of smoke detection installed within five feet of the doors (no smoke detectors are installed) and from activation of the sprinkler system which protects each side of the doors.

2. A pair of fire doors in the designated four hour fire wall between the Main Hospital and the receiving area are held open by means not complying with 7.2.1.8.. These fire doors lack smoke detection installed within five feet of the doors and they did not close automatically from activation of the sprinkler system which protects each side of the doors.

3. The pair of fire rated doors to the maintenance shop did not close from activation of smoke detection installed within five feet of the doors (no smoke detectors are installed) and from activation of the sprinkler system which protects each side of the doors in accordance with 19.2.2.2.6 and 7.2.1.8.


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4. At 3:30pm on 2/18/15 it was observed that the 2nd floor PT Suite Storage room door was a labeled self-closing fire rated door with a foot peg hold-open device not in compliance with 7.2.1.8.2.

Based on observation on February 17 - February 19, 2015, with the DPOM and the POM present, the surveyor observed hazardous areas which are not enclosed in accordance with 19.3.2.1. This condition could allow fire to spread beyond the areas with high fuel loads into patient areas and corridors.

Findings include:

1. The 4th floor surgical suite has a large volume of storage in the corner aisle near Operating Room # 1. The total storage is in excess of 100 Square feet and a one hour fire rated enclosure is not provided.

2. A 3rd floor pediatric storage space has a pair of fire rated doors which are not self closing in accordance with 19.3.2.1 and NFPA 80.

3. A 3rd floor dialysis storage room has a fire rated door which is not self closing.

4. The radiology south aisle has a barrel of film (highly combustible) left in the aisle. The container was not stored in a one hour fire rated enclosure.

5. The 8th floor has an access panel into a very large attic space to the east. This attic space is used as a mechanical space. A two hour fire barrier is identified on Life Safety Plans between the 8th floor corridor and the attic. The attic has been evaluated as a hazardous area. The hatch in the wall between the 8th floor corridor and the attic is not self closing.

7. A 6th floor storage room (Room 614) lacks a 3/4 hour fire rated door.

8. The 2nd floor Outpatient Pharmacy is not separated from the adjacent corridor by smoke tight construction in accordance with 8.4.1.2. It is located on a floor with no -inpatient sleeping or treatment. the floor is mixed use, storage. business, assembly in a health care build. The outpatient pharmacy was renovated approximately in 2006 and is a hazardous area under 38.3.2.1 and 12.3.2.1.3.

Based on observation during the survey walk-through, while accompanied by the Security Officer, not all hazardous areas are separated from the remainder of the building in accordance with 39.3.2.1 and 8.4.1. 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 the building's exit access paths.

Findings include:
1. At 1:00pm on 2/18/15 it was observed that the building furnace room containing gas fired appliances was not sprinklered or otherwise separated by 1-hour construction to comply with 39.3.2.1, 8.4.1, 8.2.3.2.1 and NFPA 80. Walls & penetrations were not protected and the room lacked a minimum 3/4-hour fire rated door assembly.

Based on observation during the survey walk-through, while accompanied by the Security Officer, the surveyor found that the not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1, 39.3.2.1 and 8.4.1. These deficiencies could affect all staff and visitors present, as well as patients within the building by allowing smoke and fire to compromise exit access within building.

Findings include:
1. At 1:40pm on 2/17/15 it was observed that the 4th floor corridor accessing the On-Call rooms in the unsprinklered portion of the building was being used to store 15 garbage bags full of used clothing. A closet (former phone booth room) at this location was also being used as a "bin" for used clothing. The requirements of 19.3.2.1, 19.7.5.5, 39.3.2.1 and 8.4.1 are not met because the quantity and density of used clothing is deemed to be a hazard greater than that normal to the general occupancy and is not separated by 1-hour construction or stored separately in an area protected by automatic sprinkler system.

2. At 2:45pm on 2/17/15 it was observed that the 3rd floor Storage room 310 was not sprinklered and not separated by 1-hour rated construction including a minimum 3/4-hour rated self-closing door assembly to comply with 39.3.2.1 and 8.4.1.

Based on observation during the survey walk-through, while accompanied by the Security Officer, exits are not provided in accordance with 38.2.4. Failure to provide required exits can compromise the safety of all occupants relying on exits to reach safety.

Findings Include:
1. At 2:15pm on 2/18/15 it was observed that the Little Village facility has a second floor area which is currently unoccupied as part of the business function, but the fire alarm panel and electrical panels are located at this level. It is used only for minor general storage. Although this floor area is described as a mezzanine, it does not comply with NFPA 101-2000, 8.2.6 as a mezzanine because it is not open to the floor area below to comply with 8.2.6.3 and the area is not otherwise provided with at least two means of egress with not less than one means of egress providing direct access to an exit at the floor area level to comply with the exception to 8.2.6.3. The travel distance from the farthest point to the stair appeared to exceed the 100' distance permitted by any of the 38.2.4.2 exceptions. The stair provided as the only exit is not enclosed at the ground floor level to comply with 7.2.2.5.

Based on observation on February 17, 18 and 19, 2015, with the DPOM and POM present, the surveyor finds that two required exit stairs do not comply with provisions of Chapter 7 of NFPA 101. the use of exit enclosures for systems which are not permitted in the exit could compromise the use the exit in an emergency.

Findings include:

1. Two required exit stair enclosures are used for purposes or have systems which do not serve only the exit. The recent installation of data boxes and data systems conduit in one or more exit stairs of the main hospital does not comply with 7.1.3.2.1. Locations include:

a. South/center exit stair

b. 6 west exit stair

Based on observation on February 17-19, 2015, with the DPOM and POM present, the surveyor find that multiple required exit stairs do not comply with provisions of Chapter 7 of NFPA 101.

Findings include:
1. The east middle exit stair enclosures was used for purposes or have systems which do not serve only the exit and do not comply with 7.1.3.2.1. This includes the none-fire-rated hatch (access to mechanical spaces below) in the 1st Floor landing of the middle annex exit stair.

a) The hatch does not latch without manual help.

b ) The hatch is not B label opening protective.

c) The hatch is not permitted in an exit stair.

2. The required middle annex exit stair has handrails on the interior side of the stair and not on both side of the stairs in accordance with 7.2.2.4.2.

3. 1st Floor, the exit passageway from the middle annex stair has three doors. One has a continuous hinge which is listed for a 1 1/2 hour door; however there is no UL label on the door.

A. Based on observation on February 17-19, 2015, with the DPOM and POM present, the surveyor observed multiple exit stairs have an exit discharge to the outside which are obstructed enough to render them unusable or hazardous as an exit discharge. A safe and unobstructed path to a public way was not provided in the event of an emergency accordance with 7.7 of NFPA 101. These conditions will delay patient evacuation in an emergency.

Findings include:

1. The exit discharge into the area between the Main Building and the Service Building was covered with a thick layer of Ice and snow. This discharge path served as the exit discharge for a require exit stair serving multiple patient floors and as the exit discharge for a 1st floor exit access corridor.

2. The Main Building northwest exit stair serves multiple patient floors. It discharges to the north into the ambulance bay, under an exterior canopy. The path directly to the north has a concrete wheel stop which is a tripping hazard. No barriers or warnings are installed. The intended path to the east was obstructed by snow and a wall mounted steel shelf (about head high).

B. Based on observation on February 17-19, 2015, with the DPOM and POM present, the surveyor observed that exit paths are locked or obstructed and dead-end conditions in excess of thirty feet exist which do not comply with 7.2.1.6.1 and/or 19.2.5.10. This condition will delay patient evacuation in an emergency.

Findings include

1. The back exit access corridor in the 1st floor Imaging Department is not identified as part of a suite. The back aisle is continuous lined with equipment which obstructs the the aisle to less than 44" in clear width. A door to the outside is marked as an exit; however, the 1st step is 16" in height; this step does not comply with 7.2.2.1(a). This creates a dead-end condition in excess of 70'.

2. The 7th floor exit access corridor to the east has a 40' dead-end condition. This portion of the corridor has access to only one exit. The door to the east enters a psychiatric unit and is locked against entry. This corridor does not comply with 7.5.1.6, 19.2.5.10, and 19.2.4.

3. The 5th floor Mother/Baby Unit has an electronically locked door that does not comply with 7.2.1.6.1.

a. The door lacks a sign in accordance with 7.2.1.6.1 (d).

b. The door lacks an audible alarm in accordance with 7.2.1.6.1 (c).

c. The door has a lever latch-set which requires special knowledge to operate and release the door lock. The door is not a push and release device in compliance with 7.2.1.5.1.

6. Room 464 on a psychiatric floor was observed with the DPOM and SO present with a locked bathroom door. The provider was not able to unlock this door. This locked doors does not comply with providers written procedures for locked doors in a psychiatric unit.

7. The locked door in the corridor between the 6th floor ICU and the Diagnostic Center creates a 40' dead-end corridor.


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Based on observation during the survey walk-through, while accompanied by the Security Officer, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1, and Chapter 7. These deficiencies could affect all staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:
8. At 10:15am on 2/18/15 it was observed that the 1st floor cross corridor doors marked as an available exit from the Ambulance Entrance Elevator 'B' Lobby was equipped with a dead bolt lock in addition to latching hardware which can require two releasing operations to open the doors in non-compliance with 7.2.1.5.4.

Based on observation during the survey walk-through, while accompanied by the Security Officer, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1, 39.2.1.1 and Chapter 7. These deficiencies could affect all staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:
1. At 2:30pm on 2/17/15 the 3rd floor pharmacy inner door was observed to be an outswinging dutch door which is equipped with a lockset on the lower leaf and a dead bolt lock to the frame on the upper leaf. A slide bolt is also provided to engage the top leaf with the bottom leaf. The hardware arrangement does not comply with 7.2.1.5.4 because the top and bottom leafs can be secured independently from each other and prevent opening of the door with a single releasing operation. The bottom leaf is not provided with a device to swing the top leaf when the bottom leaf is unlatched and opened for the purpose of egress.

2. At 1:45pm on 2/17/15 it was observed on the 4th floor and also 2:30 on 3rd floor and 3:10pm on the 2nd floor that the north annex stair is considered to be a communicating stair and not an exit stair. However, exit signs are provided in the corridors of the Annex outside the stair to indicate a required exit path toward the communicating stair, but signage on the stair door reads "Not an Emergency Exit". No signage is provided at the communicating stair door to indicate that the exit path is through the stair to access the main hospital northwest exit stair to comply with 39.2.10 & 7.10.1.4. The doors on the main hospital side of the communicating stair swing into the stair and not in the direction of exit travel from the Annex toward the northwest stair of the main hospital to comply with 7.2.1.4.2.

Based on document review of Life Safety Plans date 09/06/13, based on personnel interview on 2/17/15 with the DPOM, POM, and SO and based on the survey walk-thru on 2/18/15, the surveyor find that building separations and two hour fire barriers (or greater) 8.2.2 and 8.2.3 are not provided in accordance with 18.3.7.1 through 18.3.7.7.
Failure to provide and maintain fire compartmentalization where required will limit where patients can be evacuated to in case of an emergency.

Findings include:

1. The two hour fire barrier identified on the Life Safety Plans date 09/06/13 at the east end of the 1st floor corridor is not constructed to be a two hour fire barrier.

2. The four hour fire barrier identified on the Life Safety Plans date 09/06/13 at the 1st floor south side of the hospital (separates the hospital from the Service building) is required to be at least a two hour fire barrier in accordance 19.1.1.4.1. The window openings in the south wall, containing window air conditioners, is not constructed to comply with 8.2.3 as a two hour fire barrier.

Based on observation during the survey walk-through, while accompanied by the Security Officer, not all designated or required fire barriers are maintained as fire resistive assemblies in accordance with 19.2.2.5. and 8.2.3.2. Failure to maintain fire barriers can compromise the intended function of providing protective features of the building for occupant safety during a fire emergency.

Findings include:
At 2:00pm on 2/17/15 it was observed that the 4th floor 2-hour barrier which was identified as separating the sprinklered portion of the Annex building from the non-sprinklered was not constructed to provide a 2-hour rated assembly. The plaster ceiling has been removed at the Mechanical room adjacent the Center Exit Stair and the wall was not full height to the bottom of the roof deck to provide complete separation of the Stair in accordance with 7.1.3.2.1(b). Piping from the Mechanical room which penetrated the 2-hour barrier wall as observed above the lay-in ceiling in the Men's Toilet room to lack protection in accordance with 8.2.3.2.4.2.

Based on observation and staff interview during the survey walk-through, while accompanied by the Security Officer, exit discharge locations are not provided with illumination to comply with 38.2.8, 38.2.9, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:
1. At 2:00pm on 2/18/15 it was observed that the lighting provided at the east exterior exit doors and the access to the public way were HID type and not of the instant-on type (incandescent, fluorescent, quartz or LED) to provide lighting of the means of egress in accordance with 7.8.1.2 and 7.8.1.4. This lighting was also not provided with an alternate power source to provide emergency lighting in accordance with 38.2.9.1 and 7.9.

Based on observation and staff interview during the survey walk-through, while accompanied by the Security Officer, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:
1. At 3:00pm on 2/18/15 it was observed that the lighting provided at the east stair exterior exit door and the access to the public way were HID type and not of the instant-on type (incandescent, fluorescent, quartz or LED) to provide lighting of the means of egress in accordance with 7.8.1.2 and 7.8.1.4.

Based on observation during the survey walk-through, while accompanied by the Security Officer, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1, 39.2.10 and 7.10. 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:
1. At 3:15pm on 2/18/15 it was observed that exit signage is provided at the 2nd floor medical staff office which directs an exit path through the medical records storage area (hazardous area) is non-compliant with 7.5.1.7.

Based on the review of fire drill documentation for the previous twelve months and based on interview of the SO, the surveyor finds that fire drills are not always conducted in accordance with 19.7.1.2. Failure to close all doors, including any which area by passed during a fire emergency will allow fire and smoke to spread beyond the location of fire origin.


Findings include:

On 02/17/15 in the morning, the surveyor observed that the door functions, particularly smoke door functions, are by-passed routinely on fire drills (3/5/14, 3/19/14, 5/6/14, 7/31/14, 11/28/14 for example). However the provider does not observe and document on fire drills that staff will close all doors which are by-passed in accordance with the written fire plan and 19.2.7.2.

Based on the review of documentation with the DPOM and SO and based on the interview of the SO, the surveyor finds that fire drills are not always conducted in accordance with 19.7.1.2. Failure to close all doors, including any which area by passed during a fire emergency will allow fire and smoke to spread beyond the location of fire origin.


Findings include:

On 02/17/15 in the morning, the surveyor observed that the door functions and particularly smoke door functions are by-passed routinely on fire drills (3/5/14, 3/19/14, 5/6/14, 7/31/14, 11/28/14 for example). However, the provider does not observe and document on the fire drills that staff will close all doors which are by-passed in accordance with their written fire plan and 19.2.7.2.

Based on observation during the survey walk through, while accompanied by the Security Officer, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA 72-1999. This could affect all occupants of the building if the fire alarm system does not operate properly during a fire emergency.

Findings include:
1. At 2:30pm on 2/18/15 it was observed that the fire alarm system did not comply with all requirements of NFPA 72-1999, 1-5.2.5.2. The fire alarm control panel was not labeled to identify the electrical circuit and panel from which it is fed and the electrical panel circuit feeding the fire alarm control panel did not include a lock-on device.

Based on observation during the survey walk through while accompanied by the Security Officer, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA 72-1999. This could affect all occupants of the building if the fire alarm system does not operate properly during a fire emergency.

Findings include:
1. At 1:30pm on 2/17/15 it was observed that the smoke detector located in the south Elevator Penthouse (accessed from the roof) was not mounted at the ceiling junction box. The detector was hanging from wires 12" or more from the ceiling surface and not in compliance with NFPA 72-1999, 2-3.4.3.1.

Based on observation during the survey walk through, while accompanied by the Security Officer, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA 72-1999. This could affect all occupants of the building if the fire alarm system does not operate properly during a fire emergency.

Findings include:
1. At 3:20pm on 2/18/15 it was observed that the smoke detector located in the janitor room adjacent the Financial Counselor office was not mounted at the ceiling surface in noncompliance with NFPA 72-1999, 2-3.4.3.1.

The following deficient practice will allow products of combustion to move from compartment to compartment.

1. At 9:45 a.m. 2/18/15 on the 3rd Floor during fire alarm testing while in the company of the Patient Experience Manager, the cross corridor fire doors by Room 333, did not close to a latched position due to the door coordinator malfunction.

2. At 10:00 a.m. 2/18/15 on the 1st Floor during fire alarm testing while in the company of the Patient Experience Manager, the cross corridor fire doors by the Cafeteria Vending Machine Room did not close to a latched position due to one door caught on the door wall pocket.

Based on observation on February 16, 2015, during the survey walk-thru accompanied by the DPOM and POM, the surveyor observe that the 1st Floor Emergency Department is contained within a required fully sprinkler fire compartment/smoke compartment. This sprinkler system is not installed and maintained in accordance with NFPA 13 - 1999. Any fire in this stair will not be controlled by a sprinkler head at the bottom of the stair.

Findings include:

1st Floor landing at the bottom of the Annex Middle Exit stair lacks sprinkler protection in accordance with NFPA 13.


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The following deficient practice will delay the extinguishment of a fire.

1. At 11:00 a.m. 2/17/2015 on the 4th floor while in the company of a Plant Operation engineer and Security Officer, the surveyor finds by direct observation the ceiling open and unfinished in the sterilizer equipment room. This deficient practice compromises the sprinkler fire protection.

Based on direct observation on February 17-19, 2015, with the DPOM and the POM present, the surveyor finds the sprinkler protection is not installed and maintained in accordance with NFPA 13 -1999. The provider has identified the Main Hospital as fully sprinklered. Based on recent renovation projects, based on the building height (8 story high rise) and based on 11.8.2 and 19.3.5 of NFPA 101 - 2000, a sprinkler system is required. Failure to install and maintain a sprinkler system could result in spread of fire, uncontrolled to multiple patient areas

Findings Include:

1. The main entrance drop off canopy which serves as the emergency room entrance, the exit discharge for a 1st floor exit path and an eight story patient exit stair, lacks sprinkler protection in accordance with NFPA 13, 4-13.7. The main entrance drop off canopy and ambulance bay is an unprotected steel structure which is attached to the hospital. Vehicles including cars, police vehicles and emergency vehicles are routinely parked under this canopy and are left unattended.

2. The following locations lacks sprinkler protection and do not comply with the exceptions for unsprinklered spaces.

a. 8th floor convenience stair - bell rope closet inside this stair lacks sprinkler protection.

b. Multiple elevator machine rooms (all elevator machine rooms except for the hydraulic machine rooms) lack sprinkler protection. See K160.

c. 6 south/center exit stair - the sprinkler pressure gauge was not functioning.

d. Laundry chute closet on multiple floors (except 7) lacks sprinkler protection.

e. 6th floor ICU staff work room - the deep niche for purses is not sprinklered.

f. 1st floor pop closet is not sprinklered.

g. 1st floor dish washing room has two of two sprinkler heads which were corroded and covered with grime. The surveyor observed that the above heads had been cleaned by the morning of 2/19/15. The DPOM was not able to identify how the heads were cleaned and why replacement is not required under NFPA 13.

h. 1st floor security video surveillance room is not sprinklered and lacks a smoke tight ceiling (room is open to ceiling cavity above).

i. The sprinkler system above the rolling files in the medical records room is obstructed and not installed in accordance with NFPA 13.

j. The space under a stair in the 1st floor kitchen lacks sprinkler protection.

k. 2nd floor outpatient pharmacy has one shelf with storage which obstructs the sprinkler system.

l. 1st floor laundry chute discharge room is open to the laundry chute vertical shaft. It lacks a draft stop around the laundry chute as a barrier for the sprinkler protection in this room.


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3. At 3:00pm on 2/18/15 it was observed that a ceiling tile had been removed at the chapel storage room to accommodate poles for vertical storage in the corner. Removal of the ceiling tile can compromise the response of sprinklers intended to be installed in accordance with NFPA 13-1999, 5-6.4.1.

4. At 3:05pm on 2/18/15 it was observed that sprinkler heads were not installed below ductwork 4' or wider in the Chapel Mechanical room in compliance with NFPA 13-1999, 5-6.5.3.1.



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5. At 2:15 p.m. 2/17/2015 on the 2nd floor while in the company of a Plant Operation Manager, the surveyor finds the Data Closet located in the mechanical room adjacent to the Chapel does not have a fire suppression system installed.

6. At 2:30 p.m. 2/17/2015 on the 1st floor kitchen while in the company of a Plant Operation Manager, the surveyor finds that all walk-in coolers and freezers are not provided with fire sprinkler protection.

The provider has identified the Service Building as fully sprinklered. Based on observation the surveyors , with the DPOM and the POM attending on February 18, 2015, find that sprinkler protection is not always installed and maintained in accordance with NFPA 13 -1999. Failure to install and maintain a sprinkler could result in spread of fire, uncontrolled to multiple patient areas.

Findings include:
1. The three story Service Building lacks an inspector's test valve which is installed to simulate the flow of one sprinkler head and which is identified with a sign. This condition was also not found and abated during quarterly or annual inspection, testing and maintenance in accordance with NFPA 25 - 1998.

Based on observation during the survey walk-through, while accompanied by the Security Officer, sprinkler systems are not installed in accordance with NFPA 13-1999. Failure to maintain the installation conditions can result in delayed response to a fire condition the sprinkler system is designed to control.

Findings include:
1. At 2:15pm on 2/18/15 it was observed that a portion of the 2nd floor area that was originally installed with lay-in ceiling system and pendant sprinkler heads had the ceiling system partially removed without the heads being re-oriented to comply with NFPA 13-1999, 5-6.4.1

Based on observation, document review and interview of the DPOM, the surveyor find the receiving corridor between the Main Hospital and the Service Building has a sprinkler system which is identified by the DPOM as an anti-freeze loop. The surveyor find that this sprinkler system in this building is not maintained in accordance with NFPA 25 - 1998. Failure to test and maintain the system could allow it to freeze and fail in a fire emergency.


Findings include:

1. Based on an interview with the DPOM on the morning of 02/17/15, the surveyor finds that there is no documentation for annual testing, service and maintenance of this anti-freeze loop system in accordance with NFPA 13 and NFPA 25. No one is testing for specific gravity, low point temperature and/or FDA approved chemical requirements.

Based on record document review, while accompanied by the Security Officer, sprinkler systems are not maintained in accordance with NFPA 13 & 25. Failure to maintain the installed sprinkler system can compromise the safety of occupants in the event of fire.

Findings include:
1. At 8:30am on 2/19/15 during document review of the sprinkler system inspection records for the Little Village Clinic, the documentation stated: "Note: Portion of Mega Mall buildings St. Anthony's space being tested by their own contractor as per Manager of St. Anthony." No other documentation of inspection and testing of the sprinkler system was available to indicate that the St. Anthony tenant space portion of the building was being tested/inspected to comply with NFPA 25-1998, Chapter 2.

Based on observation during the survey walk through while accompanied by the Facility Electrician, the surveyor found that the fire pump installation did not meet all of the requirements of NFPA-20. This could affect all occupants of the building if the fire pump does not operate during fire emergency.

Findings include:
1. The fire pump was not equipped with the four required alarm points as required by NFPA-20, Section 7-4.7: a) loss of phase, b) pump running, c) phase reversal, and d) connected to emergency source of power.

2. On Wednesday, February 18, 2015 at approximately 10:50 AM the surveyor observed that the fire pump was not served by the emergency generator.

Based on an inspection of the 1st floor kitchen with the DPOM and the POM on the morning of February 19, 2015, the surveyor finds cooking systems which are not installed and maintained in accordance with NFPA 17/17A and NFPA 96. This condition could result in a serious and uncontrolled fire in the Kitchen exhaust duct system.

Findings include:

1. The kitchen exhaust (grease) duct has multiple access panels above the ceiling in the 1st Floor kitchen which are not fire rated access panels for a grease ducts in accordance with NFPA 96

2. The main cooking line has two gas fryers which are not being used but are not disconnected from the gas line. The filter bank above the fryers has a gap which will allow any grease to bypass the grease filters.

3. No access panel for cleaning was found above the ceiling of the 1st floor kitchen for the east end of the kitchen exhaust duct where the duct changes direction from horizontal to vertical, in accordance with NFPA 96.

4. There is an electrical junction box anchored to the kitchen exhaust ducts above the ceiling in the 1st Floor kitchen, in front of the gas range. Any screw penetrations of the exhaust duct constitute a violation of NFPA 96.

5. The DPOM indicates that the hood suppression system is a dry chemical system. This system can comply with NFPA 17 but not NFPA 17A. A dry chemical system cannot comply with UL 300. The annual documentation for testing and maintenance of this hood suppression system fails to identify this system as not in compliance with UL 300. The documentation also fails to identify the system deficiencies identified under Item 1 - 5 above.

Based on observation with DPOM and the POM present, the surveyor finds that medical gas systems do not comply with NFPA 99 and/or NFPA 50. This could delay staff response in an emergency with the medical gas system.


Findings include:

1. Based on observation on the afternoon of 2/18/15, with the DPOM present, the surveyor observed a medical gas alarm panel on the 1st floor MRI corridor wall that lacked identification in accordance with NFPA 99 - 1999.


2. Based on observation on the afternoon of 2/17/15, with the DPOM present, the surveyor observed a hospital bulk oxygen system is located immediately adjacent to storage containers and two a parking area. Combustible storage is not maintained at least 25' from the bulk oxygen tanks in accordance with NFPA 50 and there are no barriers to restrict parking to no closer than 10'.

Based on observation during the survey walk through while accompanied by the Facility Electrician, the surveyor found that the generator installation did not meet all of the requirements of NFPA 110-1999. This could affect all occupants of the building if the generator does not operate during the loss of normal power.

Findings include:
1. On Wednesday, February 18, 2015 at approximately 11:00 AM the surveyor observed that the 50 kW and 200 kW generators were not equipped with remote manual stop stations in accordance with NFPA-110, Section 3-5.5.6.

2. On Wednesday, February 18, 2015 at approximately 11:05 AM the surveyor observed that the facility's remote annunciators were not located at a location that was staffed 24/7 as required by NFPA 99-1999, Section 3-4.1.1.15. The plant office is not considered 24 hour since plant personnel are often working out in the plant.

3. On Wednesday, February 18, 2015 at approximately 11:10 AM the surveyor observed that the battery charger was connected directly at the battery terminals which is not allowed by the 1999 Edition of NFPA-110, Section 5-12.6.

Based on observation during the survey walk-through, February 17 through 19, 2015, and based on document review, and staff interview, with the DPOM, POM and SO the surveyors find the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

Findings include:

A. 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 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 interim life safety measures to remain in place as work toward the completion of its PoC progresses.

.




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The following deficient practice allows for ventilation air to be circulated from the mechanical room not the outdoors as required.

B. At 2:00 p.m. 2/17/2015 on the 3rd floor while in the company of a Plant Operation Engineer, the surveyor finds AHU S3B outdoor air intake plenum open to the mechanical room. This deficient practice allows for ventilation air to be circulated from the mechanical room not the outdoors as required. AHU S3B is also the outside air source for the Compressed Patient Medical Air for the facility.

Based on observation during the survey walk-through, document review, and staff interview, with the DPOM, POM and SO the surveyors find the facility is not in compliance with the Life Safety Code and other code requirements that are documented under the K-Tags of this survey.

Findings include:
A. 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 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 interim life safety measures to remain in place as work toward the completion of its PoC progresses.

.

Based on observation with the DPOM and the POM, the surveyor observed the electrical systems and materials are not installed and maintained in accordance with NFPA 70-1999. This will delay any response in an electrical emergency, forcing removal of the stored items to get to the panels; it could cause a fire if electrical circuits cannot be turned off quickly.

Findings include:


1. At the 1st floor receiving room south of the main hospital and at the north side of the Service Building on 02/17/15 and the morning of 2/18/15 the surveyor observed multiple wall mounted electrical panels where stored items and received materials are routinely parked in front of the panels. The 3' of clear space in front of the panels are not maintained in accordance with NFPA 70.

Based on observation, with the DPOM present on February 17-19, 2015, the surveyor finds that electrical systems and materials are not installed and maintained in accordance with NFPA 70 1999. Failure to install and maintain electrical systems could result in a fire.

Findings include:

1. At 9:00AM on 02/18/15, the surveyor observed a "gravel roof storage room" with multiple electrical extension cords in permanent use.

2. At 4:05 PM on 02/17/15, the surveyor observed a 4th floor scope re-processing room with an orange extension cord in permanent use.

3. At 4:05 PM on 02/17/15, the surveyor observed in the 4th floor scope re-processing room that access to a wall mounted electrical panel is blocked by storage. The 3' of clear space in front of the panel is not maintained in accordance with NFPA 70.

4. At 1:10PM on 02/18/15, the surveyors observed a 3rd floor nurse station with an orange extension cord in permanent use.

5. At 1:00AM on 02/18/15, the surveyor observed that the surgical HVAC room has an open electrical junction box which lacks a cover.

6. At 2:15PM on 02/18/15, the surveyor observed in the MRI equipment room at back of MRI control room, that access to two electrical panels is blocked by storage. The 3' of clear space in front of each panel is not maintained in accordance with NFPA 70.

7. At 3:15PM on 02/18/15, the surveyor observed in the 1st floor security data closet, that access to electrical panels was blocked by a table and a ladder. The 3' of clear space in front of the panel is not maintained in accordance with NFPA 70. The electrical panel lacks circuit identification for every electrical circuit including spares.

8. At 3:00PM on 02/18/15, the surveyor observed in the 1st floor dishwashing room, that access to the electrical panel is blocked by permanently installed equipment. The 3' of clear space in front of the panel is not maintained in accordance with NFPA 70.



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Based on observation during the survey walk through while accompanied by the Facility Electrician,the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

9. On Tuesday, February 17, 2015 at approximately 2:00 PM the surveyor observed that the elevator cab lights in elevators B, C, D, E, and F were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32, and the elevators were not equipped with cab lighting disconnects in the elevator equipment rooms in accordance with NFPA-70, Section 620-53.

10. On Wednesday, February 18, 2015 at approximately 10:30 AM the surveyor observed that the hospital ICU rooms, C-Section room, Operating Rooms, Stage 1 recovery rooms, and labor and delivery room 506 were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-19. This could effect all patients in this area if the transfer switch failed and no normal or emergency power was available at the bed locations.

11. On Tuesday, February 17, 2015 at approximately 2:30 PM the surveyor observed that the med/surg rooms, and the Mother/Baby rooms were not equipped with critical power receptacles to meet the requirements of NFPA-70, Section 517-18.

12. On Wednesday, February 18, 2015 at approximately 10:30 AM the surveyor observed that the emergency receptacles were not labeled in all critical care areas such as the ICU rooms, labor and delivery rooms, and Operating Rooms in accordance with NFPA-70, section 517-19.

Based on observation during the survey walk-through, while accompanied by the Security Officer, not all portions of the facility's electrical distribution system are in accordance with NFPA 70-1999. Failure to maintain the electrical system can result in a shock hazard or disruption of the electrical system.

Findings include:
1. At 1:40pm on 2/17/15 it was observed that an electrical junction box at the top of Stair #5 (South Stair) lacked a cover to enclose the wiring connections within the conduit system to comply with NFPA 70-1999, 370-25.

2. At 2:00pm on 2/17/15 it was observed at the 4th floor outside the Mechanical room adjacent the center stair that open junction boxes existed above the ceiling in noncompliance with NFPA 70-1999, 370-25. It was not verified that these were abandoned, non-functional electrical systems.

Based on direct observation on February 17-19, 2015, with the DPOM, POM and SO present, the surveyor find that the elevators and elevator machine rooms do not comply with 9.4.6 of NFPA 101 along with ANSI A17.3 (National Elevator Code).

Findings include:

1. Documentation and certifications of elevator fire department recall, in accordance with ANSI A17.3 was requested during the initial entrance interview at 8:30AM on February 17, 2015. Although the provider has documentation, the documentation did not demonstrate fire department recall, to primary and alternate floors, for every elevator in accordance with ANSI A17.3.

a. The annual testing and maintenance documentation did not clearly identify every floor and every elevator. The documentation did not certify testing conducted in accordance with ANSI A17.3.

b. According to the DPOM monthly testing of fire department elevator recall is not conducted in accordance with ANSI A17.3.



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Based on observation during the survey walk-through, while accompanied by the Security Officer, Elevators are not provided with elevator recall in accordance with ASME/ANSI A17.3 and 19.5.3, 39.5.3, and 9.4.3.2. Failure to maintain firefighter and recall operation of the elevators can compromise occupant safety & escape and prevent firefighter use in accessing fire locations.

1. At 2:50pm on 2/17/15 it was observed that the south elevator of the Annex building was identified by staff to be non-operational. It was not clearly evident that this elevator was equipped with elevator recall or clearly identified to occupants as being out of service.

The above elevator and the electrical equipment in the elevator machine room were not tagged out in accordance withe NFPA 70 to indicate that the equipments was not functioning.

Based on direct observation on all three days of the survey, February 17-19, 2015, with the DPOM, POM, and SO present, the surveyors find that the elevators and elevator machine rooms do not comply with 9.4.6 of NFPA 101 along with ANSI A17.3 (National Elevator Code).

Findings include:

1. Documentation and certifications of elevator fire department recall, in accordance with ANSI A17.3 was requested during the entrance interview at 8:30AM on February 17, 2015. The documentation presented by the provider did not demonstrate annual testing of fire department recall, to primary and alternate floors, for every elevator in accordance with ANSI A17.3.

a. The annual testing and maintenance documentation did not clearly identify every floor and every elevator. The documentation did not certified testing conducted in accordance with ANSI A17.3.

b. According to the DPOM monthly testing of fire department elevator recall is not conducted in accordance with ANSI A17.3.

c. Although the hydraulic elevator machine room for Elevator B has sprinkler protection, one of two sprinkler heads lacks a heat detector installed within two feet of each head. There is no evidence of a shunt trip to shut down the elevators before activation of sprinkler protection for Elevator B and/or for five of five elevators. The use of the Elevator B machine room for storage, particularly combustible storage does not comply with ANSI A17.3.

d. During fire alarm testing on 02/18/15 at 10:00AM, the surveyor observed that one of the elevators recalled to the 1st floor which a sprinkler flow switch was tested. This elevator had to be reset once the fire alarm was reset. The DPOM indicated that all elevators automatically recall (fire department recall) any time any sprinkler flow switch activates in the building activates. based on this the surveyors find automatic fire department recall is not limited to only the activation of elevator Lobby smoke detection and from smoke detection in elevator machine rooms, in accordance ANSI A17.3, 2.27.3.2.