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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. Corrected 10/07/15.

2. Corrected 10/07/15.

3. Corrected 10/07/15.

4. Corrected 10/07/15.

5. Corrected 10/07/15.

7. Corrected 10/07/15.

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, 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. Corrected 10/07/15.

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. Corrected 10/07/15.

3. Corrected 10/07/15.

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. Corrected 10/07/15.

2. Corrected 10/07/15.

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. [Aisle obstructions corrected 10/07/15] 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. Corrected 10/07/15.

3. Corrected 10/07/15.

6. Corrected 10/07/15.

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. Corrected 10/07/15.

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. Corrected 10/07/15.

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. Corrected 10/07/15.

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 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. Corrected 10/07/15.

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

c. Corrected 10/07/15.

d. Corrected 10/07/15.

e. Corrected 10/07/15.

f. Corrected 10/07/15.

g. Corrected 10/07/15.

h. Corrected 10/07/15.

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

j. Corrected 10/07/15.

k. Corrected 10/07/15.

l. Corrected 10/07/15.



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3. Corrected 10/07/15.

4. Corrected 10/07/15.



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5. Corrected 10/07/15.

6. Corrected 10/07/15.

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 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. Corrected 10/07/15.

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 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. Corrected 10/07/15.

2. Corrected 10/07/15.

3. Corrected 10/07/15.

4. Corrected 10/07/15.

5. Corrected 10/07/15.

6. Corrected 10/07/15.

7. Corrected 10/07/15.

8. Corrected 10/07/15.



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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 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. Corrected 10/07/15.



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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. Corrected 10/07/15.

b. Corrected 10/07/15.

c. Corrected 10/07/15.

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.