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Based on observations, it was determined that the facility failed to maintain the minimum Construction Type for this building. This deficient practice could compromise the fire resistant rating of the structure and affect staff and visitors within a means of egress.

The finding is:

On 02/26/2018 at 11:20AM while accompanied by the DPO unprotected bottom flange of a fire proofed steel beam was observed. Location observed penthouse for elevators #12, 13 and 14 with the beam located above the 480 volt electrical panel. This condition does not comply with Table 19.1.6.1, 19.1.6.4 and 19.1.6.5.

Based on observation during the survey walk-thru, means of egress are not maintained to provide protected and unimpeded paths to exits. This deficient practice could affect patients, staff and visitors if a failure to provide compliant paths compromise access and a level of safety for occupants.

The finding is:

On 02/27/18 at 10:10 AM while accompanied by the AVP and SSM, the surveyor observed that the arrangement of one of the means of egress near the Fourth Floor Elevator Lobby corridor passes through two intervening rooms of the designated Maternal Fetal Medicine Suite. This does not comply with 19.2.5.4 and 7.5.1.

Based on observation during the survey walk-through, not all egress doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress under emergency conditions could be impeded if they are not maintained

The finding is:

On 02/27/2018 at 1:40 PM, while accompanied by the AVP and SSM, observation determined that exit doors, with delayed -egress locking mechanisms are not properly identified with readily visible, durable signs located on the door leaf in the direction of the egress. This does not comply with 7.2.1.6.1.1 (4).

Example Locations include:

1. Second Floor, Med/Surg - Observation Unit, Exit Stair Door across the Unit Clerk (Nurse Station).
2. Fifth Floor, the pair of cross corridor doors west of Stair # 6.

Based on observation, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor during a fire emergency.

Findings include:

On 02/27/2018 at 10:15AM while accompanied by the LSCO a pair of entry doors were observed having a manual throw which was not engaged. Upon closing the doors, the surveyor was able to push on one door which opened both. Upon closing the doors again, they did not latch in order to comply with 19.3.2.1 and 8.4.1. Location observed 1st floor O.R. - Substerile room #3 pair of corridor doors.

Based on observation, horizontal sliding doors within the means of egress do not provide the means of maintaining the doors in the closed and latched position. This condition does not restrict the movement of smoke from one compartment to another in case of a fire emergency.

The finding includes:

On 02/27/2018 at 11:15 AM while accompanied by the LSCO the surveyor observed pairs of horizontal sliding doors as part of the designated means of egress, which did not comply with 7.2.1.14 (5) meeting the requirements for self closing doors or having a door installation being readily operable from either side 7.2.1.14 (1). Locations observed:

1. 1st floor, south end of corridor which is located on the west side of PACU suite.
2. 1st floor, north wall of PACU suite (2,557 s.f.).

Based on observation during the survey walk-through, not all stair components used within an exit stair are constructed to maintain compliant means of egress to an exit discharge. These deficiencies could affect any patients, staff, or visitors by preventing them from evacuating the building under fire conditions.

Findings include:

A. On 02/26/2018 while accompanied by the LSCO the distance between guardrails in exit stair enclosures was observed to be in excess of 4" which does not comply with 19.2.2.3, 7.2.2.4.5.3 and 7.2.2.4.5.3 (1).
Example locations include:

1. 10:15am 02/26/2018 Exit Stair # 2
2. 11:15am 02/26/2018 Exit Stair # 1
3. 11:35am 02/26/2018 Exit Stair # 4

B. On 02/26/2018 at 11:20 AM while accompanied by the LSCO the installation criteria for guardrails/handrails was observed not to comply with 7.2.2.4.3 in order to prevent projections which might engage loose clothing. This condition was observed within Exit Stair # 1 on the inside handrail at landings and switchbacks.


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

The finding is:

C. On 02/26/2018 at 11:00AM while accompanied by the LSCO an incomplete stair enclosure was observed. Windows within the stair are exposed to windows on the building's floors. The exposure provided is less than 10' apart and less than 180 degrees from window to window. This does not maintain the required fire resistance rating of the stair's enclosing walls to comply with 7.2.2.5.2 and 19.1.6.1.
Location observed: Exit Stair #2 on levels 1 - 5

Based on observation and interview, the facility provided Life Safety Floor Plan indicates horizontal exits which are not constructed and maintained in accordance with requirements. Failure to provide compliant exits can permit the effects of a fire/smoke event to expose and compromise the safety of occupants on other floor levels.

Findings include:

On 02/26/2017 at 1:30 PM while accompanied by the DPO, LSCO, AVP, it was observed that not all designated horizontal exits are provided with manual pull stations within 60 inches of exit doorways. This does not comply with NFPA 72 2010 17.14.6.

Example Locations include:
1. The Horizontal exit on the Fifth Floor adjacent to the Behavioral Unit.
2. The Horizontal exit on the Fourth Floor near the Level 2 Nursery.

Based upon observation, not all areas of the building are provided access to at least two compliant means of egress. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building under emergency conditions could be impeded if complaint exit and exit discharges are not provided.

The finding is:

On 02/28/2018 at 9:00AM while accompanied by the LSCO and the DPO an exit discharge was observed at floor level B-2, corridor directly south of the Emergency Department and adjacent to the O.R. Stair. The corridor no longer discharges but exits into a vinyl covered canopy which extends the travel distance and does not comply with the following:

1. Construction requirements of 19.3.6.2.
2. Corridor travel has been extended which does not comply 19.2.6.2.
3. The corridor extension lacks sprinkler protection, and smoke detection which does not comply with 19.3.5
4. The corridor finish material at the canopied extension does not comply with 19.3.3.

Based on observation during the survey walk through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The finding is:

On 02/27/2018 at 10:25AM while accompanied by the LSCO, means of egress corridors were observed containing multiple pieces of equipment stored along walls. Materials block part of the egress path. The surveyor was informed this is not a suite, therefore the existing condition does not comply with 19.2.5.7.1.3 (C) (1) and (2).
Location observed:

1. 1st floor semi restricted corridors adjacent to all Operating rooms.

Based on observation, the facility failed to provide exit paths that are maintained as a continuously protected path to a public way. This deficient practice could affect staff and patients during egress due to a fire emergency evacuation from the building.

The finding is:

On 02/27/2018 at 2:30 pm while in the company of the LSCO and DPO the directed exterior means of egress was observed from exit Stair #10 along a path directly adjacent to a wood slat fence of approximately 5'-0" tall by 25'-0" long surrounding the generator. This does not provide a level of safety or dependability should there be a compromised condition provided by the combustible material of the generator enclosure. This condition does not comply with 19.7.3.1 for the dependability and protection from exterior fire exposure.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. 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:

On 02/27/2018, while accompanied by the AVP and the SSM, exit signage was observed to be partially obstructed or missing which provides for dead end corridor conditions, and further does not comply with 19.2.5.2, 7.5.1, 7.10.1.2.1 or 7.10.1.5.1. Example locations:

1. At 1:40 PM at the Fifth Floor, ICU exit access corridor.
2. At 9:42 AM, at the 4th Floor , Mother /Baby Unit exit access corridor.
3. At 10:35 AM, at the 2nd Floor Med / Surg Unit Atrium.


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4. At 9:00 AM 5th floor ICU corridor.
5. At 9:15 AM 1st floor O.R. elevator corridor
6. At 9:19AM B-2 floor corridor adjacent to room #AB412.

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

The finding is:

On 02/27/2018, at 2:50PM while accompanied by the LSCO it was observed that floor level B-2, Stair #10 exit enclosure was not completely enclosed with a minimum 2-hour fire rated construction to comply with 8.3.5.1, 8.3.5.7, and 9.2.1 due to a duct installation which lacks a through wall damper. Location observed the wall between 4B Storage room and the Stair # 10.

Based upon observation, sprinklered hazardous areas are not separated by a minimum of smoke resisting construction. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

Findings include:

A. On 02/27/2018 at 9:45AM while in the company of the LSCO the 1st floor level Recovery suite contains a recovery bay with shelving along the length of two walls. The shelves contain materials and equipment wrapped in plastic and laying within plastic bins. The amount of combustibles has changed the function of this room which does not meet the requirements of 19.3.2.1.2 and 19.3.2.1.3 for self closing and latching doors.

B. On 02/27/2018 at 10:15AM while accompanied by the LSCO the 1st floor O.R. Soiled Holding room was observed to contain two open trash cube trucks containing bags of trash. The overall gallon capacity for each truck exceeds 150 gal. Therefore, based upon a room of approximately 144 s.f. this does not comply with 19.7.5.7.1 for allowable .5 gallon per square foot.

Based on observation during the survey walk through the facility failed to correctly install components of the piped medical gas system. This deficient practice can result in an increased fire/explosion hazard affecting patients, staff and visitors.

The finding is:

On 2/27/18 at 1:10 PM in the company of the DPO while touring the Cardiac Cath Department, it was observed the installation of the medical gas zone valves within the catheterization procedure room and not located immediately outside the room as required. NFPA 99, 2012, 5.1.4.8

Based on observation the facility failed to connect the grease duct system fans to duct with bolted connections. This deficient practice could result in the uncontrolled spread of fire and products of combustion during a kitchen hood fire event, which may affect patients, staff and visitors.

The finding is:

On 2/27/18 at 11:00 AM in the company of the DPO while touring the "G" Mechanical Penthouse the surveyor observed the connections between the kitchen grease ducts and the exhaust fans were made using flexible connectors which does not comply with NFPA 96, 2011, 8.1.3.4 & 5.

Based on an observation and interview, the facility failed to properly install all required initiating devices to provide a functioning fire alarm system. This deficient practice could affect patients, staff and visitors if smoke was not detected and the fire alarm system did not operate due to the placement of a smoke detector.

Findings include:

On 02/27/2018, while accompanied by AVP and SSM, the surveyor observed several smoke detectors that were located less than 3-feet from a mechanical supply vent which does not comply with 9.6, and NFPA 72 2010 Edition, 17.7.6.3.2.

Locations observed:

1. At 9:30 AM, Fourth Floor, Soiled Utility U4402.

2. At 1:30 PM, Third Floor, Med / Surg Unit, Nourishment Area near the Communication Closet, U3414.

3. At 2:20 PM, Second Floor, South East corridor near Room U2913.

Based on observation during the survey walk through the facility failed to install compliant support for the fire sprinkler system. Failure to install and maintain system could result in failure of the fire suppression system. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

A. On 2/27/18 at 9:00 AM accompanied by the DPO, it was observed that the under duct sprinkler heads in A Penthouse are supported by the ventilation duct and not from the building structure. NFPA 13, 2010, 9.2.1.3.1

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

The finding is:

B. On 2/27/18 at 1:20 PM accompanied by the DPO, it was observed sprinkler protection is not provided for the ceiling pocket created by the sky light outside Day Surgery. NFPA 13, 2010, 8.6.7.

C. On 02/27/2018 at 1:30PM while accompanied by the LSCO a means of egress corridor located adjacent to each OR was observed containing soffited alcoves. Gurnees are stored within the alcoves below continuous wall cabinets. The wall cabinets present an obstruction to adequate sprinkler protection of the back wall behind the stored gurnees. This condition does not comply with NFPA 13 2010 8.1.

Based on observation, document review and staff interview it could not be determined that components of the fire sprinkler system are tested as require. Failure to test and maintain the system could result in failure of the fire suppression system. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

D. On 2/28/18 at 9:30 AM in the company of the DPO the surveyor observed during the survey walk through, document review and staff interview, that the facility has installed flow switch testing pumps and these pumps are not recognized by NFPA. Documentation does not indicate that the fire sprinkler system alarm flow switches are tested as required by opening the inspectors test connection. NFPA 25, 2011, 5.3.3.3


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Based on observation during the survey walk through the facility failed to correctly use the essential electrical life safety circuits. This deficient practice can result in an increased loading of the life safety system affecting patients care.

The finding is:
A. On 2/26/18 at 2:32 PM in the company of the DPO while touring the fifth floor north corridor observation of Life Safety Electrical Panel #5LS2 identified the Air Conditioning Unit for Communication and IT closet U5100 are connected to circuits 13 & 15 which is not compliant with NFPA 99, 2012, 6.4.2.2.3.


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Based on observation, the facility failed to provide proper electrical identification in electrical panels. This deficient practice could affect patients, staff and visitors if proper electrical circuit is not labeled.

The finding is:
B. On 02/27/2018 at 1:30 PM, while accompanied by the AVP, it was determined that the 4th Floor, Electrical Closet, identified electrical panel directory 4SN-P is not updated. This does not comply with the requirements of NFPA 70, 2011 edition, section 408.4.