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A. Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction to comply with 19.1.6.2.

1. Location observed - First Floor Pavilion Building, Generator room. Surveyor observed unprotected steal beams supporting the floor above.

2. Location observed - First Floor Pavilion Building, Elevator machine room for Elevators A, B and C. Surveyor observed that continuous exposed wood nailers are within the roof assembly. This roof construction does not comply with NFPA 220 requirements to meet a 1-hour fire resistant roof rating for a Construction Type II (222) building.

3. Location observed - First floor West Building, Vacated Business Use space located in the Northeast corner of the building. Surveyor observed wood construction for partitions, and an elevated wood floor. This installation does not comply with a noncombustible type of construction. This area is not separated from occupied spaces due to an incomplete aluminum storefront system and walls which do not form a 2-hour fire rated separation between construction types - refer to K-Tag 044.

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A. Based on random observation during the survey walk-through, not all doors in exit access corridors comply with 19.3.6.3.

1. Pair of doors contain a coordinator that prevents the doors from closing completely. This does not comply with 19.3.6.3.1 to resist the passage of smoke. Locations observed:

a. East end of ICU "South"

b. Pavillion building, basement - Dish Room

c. Pavillion building, basement - Food Prep


2. East end of the ED waiting room contains a door with an electric strike which prevents the door from latching upon activation of the fire alarm and does not comply with 19.3.6.3.2 for a means suitable to keep the door in the closed and latched position.





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A. Based on direct observation, the facility failed to provide separation between the freight elevator machine and the maintenance department locker room and corridor. Location observed:

1. Pavillion Building, Basement - By direct observation it could not be confirmed that the required separation between elevator F machine room was provided. The room door was not provided with indication of its fire resistance capabilities.



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B. Hazardous areas were observed at which doors are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include:

1. West Building - First Floor: Closet by the Lab Area being used for storage contains a door that is not self-closing.

2. West Building - First Floor: The double doors leading to the Loading Dock / Staging Area near the Lab Area do not positively latch and are not smoke tight to comply with 19.3.2.1.

3. West Building - First Floor - Laboratory Area: Surveyor finds that the Laboratory area contains equipment, lab fixtures and stored material that is not separated from the corridor.



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C. Hazardous areas covered by sprinkler systems, lack separation from other spaces by smoke-resistant partitions and smoke tight self closing doors to comply with 19.3.2.1. Locations and conditions observed include:

1. Pavillion Building, Basement, Kitchen, Surveyor observed the Dry Goods Storage area lacked separation from occupied spaces of the Kitchen due to the lack of a smoke tight wall and a smoke tight self closing door and frame.

2. Pavillion Building, Basement, Kitchen,- Surveyor observed dedicated Storage areas that lack separation from occupied spaces of the Kitchen due to the lack of a self closing door and frame.

3. Pavillion Building, Basement, Laundry - Surveyor observed dedicated Storage areas within the Laundry room. The Laundry room is not indicated as a hazardous area to comply with 19.3.2.1.(2) on the facility Life Safety floor plans.



D. Rooms were observed with a change in function. The doors to these rooms are not self closing, smoke tight and do not latch completely. Materials were observed being stored in rooms which were not designed for a storage function and do not comply with 19.3.2.1.(7). Example locations observed:

Pavillion Building, Sixth floor, Surgery - equipment, combustible supplies, etc.
a. O.R. # 2
b. O.R. #9
c. O.R. # 10
d. O.R. # 11B

West Building, Fifth floor - mattresses, furnishings, combustible supplies, etc.
a. Room #578
b. Room # 575




E. Pavilion Building, First floor, - The Medical Records deemed a hazardous area is not designated as such on the facility Life Safety floor plans.




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A. Exit enclosures do not provide a protected path to the outside to comply with 7.1.3.2.2.:

1. Designated Exit Stair "E" discharges into a Foyer which was observed to have several unsealed conduit penetrations above the ceiling that do not comply with 8.2.5.2.

2. Designated Exit Stair D-1 discharges through a 1st Floor Exit Passageway. This exit passageway contains bulletin boards, plaques and other posting note materials that do not belong in an exit enclosure and has the potential to interfere with its use as an exit.



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B. Exit discharge enclosures (serve an exit stair) do not provide a continuous protected path of escape in order to comply with 19.3.2.
Surveyor noted that numerous exit passageways were not continuous and enclosed with the same fire resistant rating as the stairs they serve. Numerous exit passageways contain ductwork, etc. located above the suspended acoustical tile ceilings. Surveyors were unable to verify that all ductwork passing through the passagway contained a fire rated damper within the barrier. Further, all pipe and conduit penetrations are to be fire stopped. The systems which do not serve the passageway or the exit stair are to comply with 7.1.3.2.1 (e) exception No.1 and 8.2.3.2.4.
Locations observed:

Pavilion Building First floor, Stair J

Pavillion Building First floor, Stair K

West Building First floor, Stair D adjacent to Lab.

East Building First floor, Stair B



C. During staff interview the surveyor was informed that Stair B, Stair D, Stair K and Stair J are served by exit passageways. The Life Safety floor plans do not show a designation for exit passageways and these corridors do not comply with 7.1.3.2.1 and 7.1.3.2.2 for a continuous separated/protected exit to a discharge due to the following:

1. Stair K Pavillion building first floor, ED, - exit passageway was observed to contain a pair of sliding doors which are located to prevent persons from entering part of the ED. These doors are capable of being locked against egress.

2. Stair K Pavillion building first floor ED - exit passageway was observed to be open to an elevator lobby. The surveyor was informed that these elevators have fireman recall to the first floor, thereby, opening the exit passageway to a vertical shaft.

3. Stair J Pavillion building first floor - exit passageway was observed to contain an opening to an unoccupied area which does not comply with 7.1.3.2.1 (d). The surveyor observed that the entry to the Generator room and the elevator machine room is from the exit passageway.



D. The finding is that the designated exit stairs do not comply with 19.2.2.3 and 7.2.2.3.2 for landing dimensions not less than the width of the stair. The stairs are 44" wide. Multiple stairs on multiple floors have exit width restrictions within the stair at the landings. Surveyor observed stair landings with a dimensional width of approximately 32". Example locations:

Stair K-second floor - 35"

Stair J-second floor - 32"

Stair A-second floor - 38"



E. The finding is that the designated exit stairs do not comply with 7.2.2.2.1 for the dimensional criteria of existing stairs. Surveyor observed stair landings containing hose cabinets which project into the stair more than 3 1/2". The surface mounted cabinets were observed to contain only fire extinguishers. Example locations observed: Stair K and Stair D.


F. The finding is that the designated exit stairs do not comply with 7.2.1.4.4 for the minimum required swing of a door into a stair. Surveyor observed exit doors for stairs which opened into the landing and project more than 7 inches when the door is fully opened due to the amount of utilites occuping the stair. Example locations observed: Stair K, Stair J and Stair D.




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A. Dead-end corridor of excessive length was observed that does not appear to meet the requirements of 19.2.5.10. Locations observed include:

1. West Building - First Floor: Exit access corridor near the Stair D-1 exit passageway, has only one means of egress due to the exit sign location. This contitutes to an excessive dead end corridor.


B. West Building - First Floor - The door to the required exit Stair D-1 swings out into the designated passageway and portrudes more than 7 inches into the required width when fully open and does not comply with 7.2.1.4.4.


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C. Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times to comply with 19.2.1.

1. An exterior exit path was observed that did not comply with 19.2.10.1 and 7.10.2. The exterior path to the public way was not apparent. The discharge path which occurs on a exterior rooftop patio, did not indicate the direction of travel to the public way. Location observed: Exterior discharge path from Stair A.

2. An exterior exit path was observed that did not comply with 7.7.6 criteria (1) and (2) for a roof top exit due to the following:

a. The roof construction that extends over part of the basement cafeteria, mechanical rooms, pharmacy etc. is to qualify for the same 2-hour fire resistant rating of Stair A and the exit passageway through the ED serving Stair K. From observation it could not be determined that the roof construction maintains a 2-hour fire resistance rating based on a U.L. listed design.

b. The roof top exit discharge path does not provide a safe means of egress due to the following:



i. Deteriorated condition of the pavers, loose rock, chipped off pieces providing tripping hazards.

ii. The measured width of the usable egress path at the top of the exterior stair landing measures to be 26 inches in width due to the drop off of the pavers at the adjacent gravel and gutter system which does not comply with 19.2.3.3 for capacity of a means of egress.



D. The North Wing of the West Building on the Basement, 2nd, 3rd and 4th floors has a dead-end corridor that is 58 feet in length or longer.




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A. Based on random observation during the survey walk-through, not all suites are constructed or configured to comply with 19.2.5.1. Location observed: The Surgery Suite, Sixth Floor Pavilion Building. The facility representative informed the surveyor that this area constituted a suite (did not indicate as such on the Life Safety Floor Plan). This suite does not comply with 19.2.5 due to the following:

1. The square footage is in excess of 18, 000. This exceeds the maximum compliant 10,000 square feet for nonsleeping suites and does not comply with 19.2.5.7.

2. Various locations within the suite do not comply with 19.2.5.8 for the allowable travel distance to an exit. Example locations as shown:

a. Waiting room to the closest exit (Stair C) contains two intervening rooms (hallway outside of the waiting room and the hallway adjacent to Stair C), travel distance exceeds 50 feet.


b. O.R. 7-8 to Stair K contains two intervening rooms (hallway outside of the O.R, and the small hallway outside of PACU), travel distance exceeds 50 feet.

c. O.R. 4 and O.R. 5 contains intervening room(s) - O.R. 4 to Stair C question the travel distance for one intervening room not to exceed 100 feet.
O.R. 5 to the nearest exit (Stair K) question the travel distance for two intervening rooms (hallway outside of the O.R. and the hallway outside of Stair K) the travel distance exceeds 50 feet.



B. Pavillion building First floor E.D., ICU, Fifth Floor Pavilion Building. The surveyor was informed that the ICU "North" and ICU "South" constituted two different suites. The surveyor was informed that the E.D. and Triage Waiting area constituted two different suites. The Life Safety floor plan does not indicate any suites.

1. ICU - The exact size and perimeter of these suites is unknown however, they appear to exceed the allowable 5000 square feet for sleeping room suites to comply with 19.2.5.6.

2. ED - The exact size and perimeter of these suites is unknown however, they appear to exceed the allowable 10,000 square feet for non sleeping room suites to comply with 19.2.5.6.



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A. From random observation, the surveyors find that fire barriers (with two hour or greater fire ratings) are not installed and maintained in accordance with 8.2.3. This includes fire barriers that are used as horizontal exits and fire barriers that are used to separate buildings:

1. West Building First floor designated exit from Lab at the North end. Surveyor observed an exit to the exterior which required the passage through a part of the building which is a non compliant construction type. There is no fire rated building separation provided between the type II (222) and the Business use area consisting of wood construction materials (refer to K-Tag 012).



B. From random observation during testing of the fire alarm system, pairs of cross corridor barrier doors that open in the same direction did not close completely when a person passes through the "wrong door" (the one with the latching mechanism). Thus allowing the doors to hang up on one another. This condition does not allow for a complete fire barrier. Example locations observed:

1. Radiology building, Basement, - Cath Lab area

2. Pavillion building, and East building barrier, Second floor - pair of doors west of elevators A,B, C.

3. Pavillion building, and East building barrier, Third floor - pair of doors west of elevators A,B, C.










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A. Based upon random observation the required "Exits" on the First Floor Level are not accurately drawn as shown on the facility's posted Evacuation Plans. Layout of exits appears to direct occupants back into the Stairwell.


B. Based upon random observation and document review the surveyors find that the provider lacks detailed Life Safety Master Plans that define the locations of suites of rooms and exit access corridors that serve suites. The surveyors find several locations where patient treatment areas appear to be opened to exit access corridors (the surveyors are not able to confirm that such areas are within complying suites). Also, several areas have doors that lack positive latching hardware for corridor doors (again compliance as suites could not be confirmed) and corridors are obstructed with equipment where suite locations could not be confirmed.
Example locations observed: portions of these areas may be a suite because of open patient treatment bays First Floor E.R.Department, Fifth Floor Intensive Care Unit ((ICU South


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C. During a review of the facility's fire protection plan documents, compared to the survey walk through it was determined that the facility has not accurately maintained a comprehensive set of building floor plans, which show critical elements of its egress and fire/smoke compartmentalization systems, for compliance with 19.7.1.1. Critical elements of these systems which are not shown or not shown accurately on the facility's Life Safety Master Plans include:

1. Locations and sizes of smoke compartments.

2. Designated hazardous areas.

3. Exit discharge enclosures designated exit passageways and their fire resistance.



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A. Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

1. During a test of the fire alarm system it was observed that smoke barrier cross corridor doors did not close completely to comply with 7.2.1.9. Example locations observed:

a. Pavilion Building - Fifth Floor: Cross corridor doors entrance to the ICU North did not latch completely.

b. Basement - Cardiac Cath Unit: Two sets of double doors (4 hour vestibule doors) did not close to latch completely to comply with 7.2.1.9.



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B.. During the survey walkthrough it was noted that a visual alarm notification devise and smoke detection is not installed in the on-call room titled "North West Group Call Room" located in the West Building Second floor. This does not comply with NFPA 72 4-4.4.3.2.



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A. Based on direct observation, the facility failed to provide automatic sprinkler protection for the following locations: (NFPA 13, 1999, 1-6.1

1. All elevator machine rooms.

2. Emergency Generator room.

3. I & J Elevator Mechanical Room electrical room and the West Building Basement electrical room. These rooms have stored items in non-compliance with NFPA 13, 1999, 5-13.11.



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B. Based on document review and staff interview the surveyor finds the facility does not conduct a from the floor visual inspection of the installed sprinkler system annually. (NFPA 25, 1998, 2-2.1.1)


C. During the survey walk through it was noted that the facility failed to maintain finished ceilings thereby compromising sprinkler protection. Location observed:

1. West Building , First floor, Business use space located in the Northwest corner of the building adjacent to the Lab.



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A. Based on direct observation, the facility failed to provide separation of medical gas zone control valves from supplied outlets and inlets. NFPA 99, 1999, 4-3.1.2.3 (d) Locations include:

1. Pavilion Building - Sixth Floor - PACU

2. Pavilion Building - Fifth Floor - ICU North and ICU South

3. Pavilion Building - First Floor: Emergency Department.

4. Basement - Cardiac Catheterization - Recovery Bays.



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B. Medical Gas Zone shut off valves are not readily operable from a standing position to comply with NFPA 99 1999, 4-3.1.2.1. Location observed: East Building Fifth floor corridor zone valve adjacent to room # 550. Surveyor observed a shut off valve which is approximately 6 feet above the floor and not easily grasped.


C. Medical Gas Zone shut off valves are not labeled as to the area they serve to comply with NFPA 99 1999. Location observed: Pavillion Building, Second floor. The corridor zone valve located adjacent to room # 212 contains a label which reads "This valve capped for future services". Upon interviewing the facility staff, they were unsure what the label meant or if the valve was abandoned in place.



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A. Based on direct observation, the facility failed to identify all critical care electrical receptacles identified as to distribution panels and circuit number. (NFPA 70, 517-19 & NFPA 99, 3-4.2.2.4 (b)

1. Location include but not limited to PACU, ICU, etc.


B. Based on direct observation, the facility failed to provide remote manual emergency stop station for the emergency generator. (NFPA 110, 1999, 3-5.5.6)


C. Based on direct observation, the facility failed to provide a separate enclosure for the emergency generator. The generator room is open to the A, B, & C elevator machine room above.


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A. Interim Life Safety Measures: 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.

A. Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction to comply with 19.1.6.2.

1. Location observed - First Floor Pavilion Building, Generator room. Surveyor observed unprotected steal beams supporting the floor above.

2. Location observed - First Floor Pavilion Building, Elevator machine room for Elevators A, B and C. Surveyor observed that continuous exposed wood nailers are within the roof assembly. This roof construction does not comply with NFPA 220 requirements to meet a 1-hour fire resistant roof rating for a Construction Type II (222) building.

3. Location observed - First floor West Building, Vacated Business Use space located in the Northeast corner of the building. Surveyor observed wood construction for partitions, and an elevated wood floor. This installation does not comply with a noncombustible type of construction. This area is not separated from occupied spaces due to an incomplete aluminum storefront system and walls which do not form a 2-hour fire rated separation between construction types - refer to K-Tag 044.

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A. Based on random observation during the survey walk-through, not all doors in exit access corridors comply with 19.3.6.3.

1. Pair of doors contain a coordinator that prevents the doors from closing completely. This does not comply with 19.3.6.3.1 to resist the passage of smoke. Locations observed:

a. East end of ICU "South"

b. Pavillion building, basement - Dish Room

c. Pavillion building, basement - Food Prep


2. East end of the ED waiting room contains a door with an electric strike which prevents the door from latching upon activation of the fire alarm and does not comply with 19.3.6.3.2 for a means suitable to keep the door in the closed and latched position.





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A. Based on direct observation, the facility failed to provide separation between the freight elevator machine and the maintenance department locker room and corridor. Location observed:

1. Pavillion Building, Basement - By direct observation it could not be confirmed that the required separation between elevator F machine room was provided. The room door was not provided with indication of its fire resistance capabilities.



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B. Hazardous areas were observed at which doors are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include:

1. West Building - First Floor: Closet by the Lab Area being used for storage contains a door that is not self-closing.

2. West Building - First Floor: The double doors leading to the Loading Dock / Staging Area near the Lab Area do not positively latch and are not smoke tight to comply with 19.3.2.1.

3. West Building - First Floor - Laboratory Area: Surveyor finds that the Laboratory area contains equipment, lab fixtures and stored material that is not separated from the corridor.



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C. Hazardous areas covered by sprinkler systems, lack separation from other spaces by smoke-resistant partitions and smoke tight self closing doors to comply with 19.3.2.1. Locations and conditions observed include:

1. Pavillion Building, Basement, Kitchen, Surveyor observed the Dry Goods Storage area lacked separation from occupied spaces of the Kitchen due to the lack of a smoke tight wall and a smoke tight self closing door and frame.

2. Pavillion Building, Basement, Kitchen,- Surveyor observed dedicated Storage areas that lack separation from occupied spaces of the Kitchen due to the lack of a self closing door and frame.

3. Pavillion Building, Basement, Laundry - Surveyor observed dedicated Storage areas within the Laundry room. The Laundry room is not indicated as a hazardous area to comply with 19.3.2.1.(2) on the facility Life Safety floor plans.



D. Rooms were observed with a change in function. The doors to these rooms are not self closing, smoke tight and do not latch completely. Materials were observed being stored in rooms which were not designed for a storage function and do not comply with 19.3.2.1.(7). Example locations observed:

Pavillion Building, Sixth floor, Surgery - equipment, combustible supplies, etc.
a. O.R. # 2
b. O.R. #9
c. O.R. # 10
d. O.R. # 11B

West Building, Fifth floor - mattresses, furnishings, combustible supplies, etc.
a. Room #578
b. Room # 575




E. Pavilion Building, First floor, - The Medical Records deemed a hazardous area is not designated as such on the facility Life Safety floor plans.




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A. Exit enclosures do not provide a protected path to the outside to comply with 7.1.3.2.2.:

1. Designated Exit Stair "E" discharges into a Foyer which was observed to have several unsealed conduit penetrations above the ceiling that do not comply with 8.2.5.2.

2. Designated Exit Stair D-1 discharges through a 1st Floor Exit Passageway. This exit passageway contains bulletin boards, plaques and other posting note materials that do not belong in an exit enclosure and has the potential to interfere with its use as an exit.



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B. Exit discharge enclosures (serve an exit stair) do not provide a continuous protected path of escape in order to comply with 19.3.2.
Surveyor noted that numerous exit passageways were not continuous and enclosed with the same fire resistant rating as the stairs they serve. Numerous exit passageways contain ductwork, etc. located above the suspended acoustical tile ceilings. Surveyors were unable to verify that all ductwork passing through the passagway contained a fire rated damper within the barrier. Further, all pipe and conduit penetrations are to be fire stopped. The systems which do not serve the passageway or the exit stair are to comply with 7.1.3.2.1 (e) exception No.1 and 8.2.3.2.4.
Locations observed:

Pavilion Building First floor, Stair J

Pavillion Building First floor, Stair K

West Building First floor, Stair D adjacent to Lab.

East Building First floor, Stair B



C. During staff interview the surveyor was informed that Stair B, Stair D, Stair K and Stair J are served by exit passageways. The Life Safety floor plans do not show a designation for exit passageways and these corridors do not comply with 7.1.3.2.1 and 7.1.3.2.2 for a continuous separated/protected exit to a discharge due to the following:

1. Stair K Pavillion building first floor, ED, - exit passageway was observed to contain a pair of sliding doors which are located to prevent persons from entering part of the ED. These doors are capable of being locked against egress.

2. Stair K Pavillion building first floor ED - exit passageway was observed to be open to an elevator lobby. The surveyor was informed that these elevators have fireman recall to the first floor, thereby, opening the exit passageway to a vertical shaft.

3. Stair J Pavillion building first floor - exit passageway was observed to contain an opening to an unoccupied area which does not comply with 7.1.3.2.1 (d). The surveyor observed that the entry to the Generator room and the elevator machine room is from the exit passageway.



D. The finding is that the designated exit stairs do not comply with 19.2.2.3 and 7.2.2.3.2 for landing dimensions not less than the width of the stair. The stairs are 44" wide. Multiple stairs on multiple floors have exit width restrictions within the stair at the landings. Surveyor observed stair landings with a dimensional width of approximately 32". Example locations:

Stair K-second floor - 35"

Stair J-second floor - 32"

Stair A-second floor - 38"



E. The finding is that the designated exit stairs do not comply with 7.2.2.2.1 for the dimensional criteria of existing stairs. Surveyor observed stair landings containing hose cabinets which project into the stair more than 3 1/2". The surface mounted cabinets were observed to contain only fire extinguishers. Example locations observed: Stair K and Stair D.


F. The finding is that the designated exit stairs do not comply with 7.2.1.4.4 for the minimum required swing of a door into a stair. Surveyor observed exit doors for stairs which opened into the landing and project more than 7 inches when the door is fully opened due to the amount of utilites occuping the stair. Example locations observed: Stair K, Stair J and Stair D.




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A. Dead-end corridor of excessive length was observed that does not appear to meet the requirements of 19.2.5.10. Locations observed include:

1. West Building - First Floor: Exit access corridor near the Stair D-1 exit passageway, has only one means of egress due to the exit sign location. This contitutes to an excessive dead end corridor.


B. West Building - First Floor - The door to the required exit Stair D-1 swings out into the designated passageway and portrudes more than 7 inches into the required width when fully open and does not comply with 7.2.1.4.4.


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C. Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times to comply with 19.2.1.

1. An exterior exit path was observed that did not comply with 19.2.10.1 and 7.10.2. The exterior path to the public way was not apparent. The discharge path which occurs on a exterior rooftop patio, did not indicate the direction of travel to the public way. Location observed: Exterior discharge path from Stair A.

2. An exterior exit path was observed that did not comply with 7.7.6 criteria (1) and (2) for a roof top exit due to the following:

a. The roof construction that extends over part of the basement cafeteria, mechanical rooms, pharmacy etc. is to qualify for the same 2-hour fire resistant rating of Stair A and the exit passageway through the ED serving Stair K. From observation it could not be determined that the roof construction maintains a 2-hour fire resistance rating based on a U.L. listed design.

b. The roof top exit discharge path does not provide a safe means of egress due to the following:



i. Deteriorated condition of the pavers, loose rock, chipped off pieces providing tripping hazards.

ii. The measured width of the usable egress path at the top of the exterior stair landing measures to be 26 inches in width due to the drop off of the pavers at the adjacent gravel and gutter system which does not comply with 19.2.3.3 for capacity of a means of egress.



D. The North Wing of the West Building on the Basement, 2nd, 3rd and 4th floors has a dead-end corridor that is 58 feet in length or longer.




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A. Based on random observation during the survey walk-through, not all suites are constructed or configured to comply with 19.2.5.1. Location observed: The Surgery Suite, Sixth Floor Pavilion Building. The facility representative informed the surveyor that this area constituted a suite (did not indicate as such on the Life Safety Floor Plan). This suite does not comply with 19.2.5 due to the following:

1. The square footage is in excess of 18, 000. This exceeds the maximum compliant 10,000 square feet for nonsleeping suites and does not comply with 19.2.5.7.

2. Various locations within the suite do not comply with 19.2.5.8 for the allowable travel distance to an exit. Example locations as shown:

a. Waiting room to the closest exit (Stair C) contains two intervening rooms (hallway outside of the waiting room and the hallway adjacent to Stair C), travel distance exceeds 50 feet.


b. O.R. 7-8 to Stair K contains two intervening rooms (hallway outside of the O.R, and the small hallway outside of PACU), travel distance exceeds 50 feet.

c. O.R. 4 and O.R. 5 contains intervening room(s) - O.R. 4 to Stair C question the travel distance for one intervening room not to exceed 100 feet.
O.R. 5 to the nearest exit (Stair K) question the travel distance for two intervening rooms (hallway outside of the O.R. and the hallway outside of Stair K) the travel distance exceeds 50 feet.



B. Pavillion building First floor E.D., ICU, Fifth Floor Pavilion Building. The surveyor was informed that the ICU "North" and ICU "South" constituted two different suites. The surveyor was informed that the E.D. and Triage Waiting area constituted two different suites. The Life Safety floor plan does not indicate any suites.

1. ICU - The exact size and perimeter of these suites is unknown however, they appear to exceed the allowable 5000 square feet for sleeping room suites to comply with 19.2.5.6.

2. ED - The exact size and perimeter of these suites is unknown however, they appear to exceed the allowable 10,000 square feet for non sleeping room suites to comply with 19.2.5.6.



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A. From random observation, the surveyors find that fire barriers (with two hour or greater fire ratings) are not installed and maintained in accordance with 8.2.3. This includes fire barriers that are used as horizontal exits and fire barriers that are used to separate buildings:

1. West Building First floor designated exit from Lab at the North end. Surveyor observed an exit to the exterior which required the passage through a part of the building which is a non compliant construction type. There is no fire rated building separation provided between the type II (222) and the Business use area consisting of wood construction materials (refer to K-Tag 012).



B. From random observation during testing of the fire alarm system, pairs of cross corridor barrier doors that open in the same direction did not close completely when a person passes through the "wrong door" (the one with the latching mechanism). Thus allowing the doors to hang up on one another. This condition does not allow for a complete fire barrier. Example locations observed:

1. Radiology building, Basement, - Cath Lab area

2. Pavillion building, and East building barrier, Second floor - pair of doors west of elevators A,B, C.

3. Pavillion building, and East building barrier, Third floor - pair of doors west of elevators A,B, C.










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A. Based upon random observation the required "Exits" on the First Floor Level are not accurately drawn as shown on the facility's posted Evacuation Plans. Layout of exits appears to direct occupants back into the Stairwell.


B. Based upon random observation and document review the surveyors find that the provider lacks detailed Life Safety Master Plans that define the locations of suites of rooms and exit access corridors that serve suites. The surveyors find several locations where patient treatment areas appear to be opened to exit access corridors (the surveyors are not able to confirm that such areas are within complying suites). Also, several areas have doors that lack positive latching hardware for corridor doors (again compliance as suites could not be confirmed) and corridors are obstructed with equipment where suite locations could not be confirmed.
Example locations observed: portions of these areas may be a suite because of open patient treatment bays First Floor E.R.Department, Fifth Floor Intensive Care Unit ((ICU South


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C. During a review of the facility's fire protection plan documents, compared to the survey walk through it was determined that the facility has not accurately maintained a comprehensive set of building floor plans, which show critical elements of its egress and fire/smoke compartmentalization systems, for compliance with 19.7.1.1. Critical elements of these systems which are not shown or not shown accurately on the facility's Life Safety Master Plans include:

1. Locations and sizes of smoke compartments.

2. Designated hazardous areas.

3. Exit discharge enclosures designated exit passageways and their fire resistance.



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A. Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4.

1. During a test of the fire alarm system it was observed that smoke barrier cross corridor doors did not close completely to comply with 7.2.1.9. Example locations observed:

a. Pavilion Building - Fifth Floor: Cross corridor doors entrance to the ICU North did not latch completely.

b. Basement - Cardiac Cath Unit: Two sets of double doors (4 hour vestibule doors) did not close to latch completely to comply with 7.2.1.9.



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B.. During the survey walkthrough it was noted that a visual alarm notification devise and smoke detection is not installed in the on-call room titled "North West Group Call Room" located in the West Building Second floor. This does not comply with NFPA 72 4-4.4.3.2.



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A. Based on direct observation, the facility failed to provide automatic sprinkler protection for the following locations: (NFPA 13, 1999, 1-6.1

1. All elevator machine rooms.

2. Emergency Generator room.

3. I & J Elevator Mechanical Room electrical room and the West Building Basement electrical room. These rooms have stored items in non-compliance with NFPA 13, 1999, 5-13.11.



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B. Based on document review and staff interview the surveyor finds the facility does not conduct a from the floor visual inspection of the installed sprinkler system annually. (NFPA 25, 1998, 2-2.1.1)


C. During the survey walk through it was noted that the facility failed to maintain finished ceilings thereby compromising sprinkler protection. Location observed:

1. West Building , First floor, Business use space located in the Northwest corner of the building adjacent to the Lab.



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A. Based on direct observation, the facility failed to provide separation of medical gas zone control valves from supplied outlets and inlets. NFPA 99, 1999, 4-3.1.2.3 (d) Locations include:

1. Pavilion Building - Sixth Floor - PACU

2. Pavilion Building - Fifth Floor - ICU North and ICU South

3. Pavilion Building - First Floor: Emergency Department.

4. Basement - Cardiac Catheterization - Recovery Bays.



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B. Medical Gas Zone shut off valves are not readily operable from a standing position to comply with NFPA 99 1999, 4-3.1.2.1. Location observed: East Building Fifth floor corridor zone valve adjacent to room # 550. Surveyor observed a shut off valve which is approximately 6 feet above the floor and not easily grasped.


C. Medical Gas Zone shut off valves are not labeled as to the area they serve to comply with NFPA 99 1999. Location observed: Pavillion Building, Second floor. The corridor zone valve located adjacent to room # 212 contains a label which reads "This valve capped for future services". Upon interviewing the facility staff, they were unsure what the label meant or if the valve was abandoned in place.



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A. Based on direct observation, the facility failed to identify all critical care electrical receptacles identified as to distribution panels and circuit number. (NFPA 70, 517-19 & NFPA 99, 3-4.2.2.4 (b)

1. Location include but not limited to PACU, ICU, etc.


B. Based on direct observation, the facility failed to provide remote manual emergency stop station for the emergency generator. (NFPA 110, 1999, 3-5.5.6)


C. Based on direct observation, the facility failed to provide a separate enclosure for the emergency generator. The generator room is open to the A, B, & C elevator machine room above.


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A. Interim Life Safety Measures: 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.