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Based on observation on June 9, 2016, with the DPOM and the POM present, the surveyor observed the following.

Finding includes:

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, 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 17-19, 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.

Based on observation on June 9, 2016, 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 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 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. Corrected 06/09/16

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


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


i. Corrected 06/09/16



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14416

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, 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.



14416


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.

17659

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. Corrected 03/27/16

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.