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Based on direct observation not all doors in exit access corridors are available at all times for egress. This deficiency could affect all patients in the locations as well as any staff and visitors present, by compromising the direction of egress within a room or exit access corridor.

The finding is:

A. On 6/14/2017 at 11:50am while accompanied by the DoF, doors were observed which lack proper egress hardware to comply with 19.2.2.2.4.

Example locations include:

1. Pair of Kitchen entry doors contain padlock and hasp on the egress side.
2. Both the Kitchen walk in cooler and freezer contain padlock and hasp on the egress side.
3. Dry goods storage room with in the Kitchen contains a padlock and hasp on the egress side.

Based on direct 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:

On 06/14/2017 at 10:45 am while in the company of the DoF, it was observed that the enclosure walls of an exit stair are incomplete. The perimeter walls of Stair V-V (as shown on original construction documents) do not continue to the underside of the deck above as shown on the original documents. The plaster ceiling within the stair is not shown on the drawings to have a fire rating. Therefore this stair which extends 3 stories does not maintain the fire rating to comply with 19 3.1.1 and 8.3.1.1

Based on direct observation not all vertical openings between floor levels are 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.

Finding include:

A. On 06/14/2017 at 1:45 pm while in the company of the DoF, it was observed that numerous locations contain ceiling or wall access panels which are not self closing and lack a U.L. listed label per the fire resistance rating of the floor deck or vertical shaft enclosure. This condition does not comply with 19.3.1.1

Locations observed:
1. Kitchen alcove containing staff lockers has a wooden ceiling access panel.
2. Physical Therapy office located on the First floor at the end of the South West corridor has a wooden ceiling access panel.
3. Storage room located across from the elevator machine room contains an unprotected floor opening.
4. Storage room located behind the elevator machine room contains a vertical shaft with an opening covered by an unattached piece of gypsum board.


B. On 06/14/2017 at 2:15 pm at a small closet connected to the private dining room, while in the company of the DoF it was observed that a hole provided for a tube penetrating through a gypsum board ceiling is not sealed against fire and smoke to comply with 19.3.1.1.

Based on direct observation not all hazardous areas are separated from the remainder of the building. 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 adjacent areas and the building's exit access corridors.

Findings include:

A. On 06/14/2017 at 2:40pm in the "Old O.R." while accompanied by the DoF, the area appears to be abandoned and undergoing demolition. The perimeter wall cavity of the hazardous area is open to adjacent areas along with a means of egress corridor. This area does not comply with 19.3.2.1 for a minimum 1-hour enclosure.

B. On 06/14/2017 at 1:50pm in the Kitchen while accompanied by the DoF, the staff locker alcove contains multiple shelves with styrofoam cups wrapped in plastic along with cardboard boxes. This material is quickly combustible and emits toxic gases. This hazardous area is open to an adjacent means of egress. This area does not comply with 19.3.2.1 for a minimum 1-hour enclosure.

Based on direct observation the facility failed to provide a complete kitchen hood system. This deficient practice creates a high risk of fire and allows the spread of flames should a fire under the hood occur.

Findings include:

A. On 06/14/17 at 1:15 pm while accompanied by the DoF, the kitchen hood installation was observed to lack an enclosed metal container for grease collection from the kitchen hood's perimeter grease drip tray. This condition could allow for the grease collected by the grease filter to remain in the tray creating a high risk of fire should flames develop from the cooking procedures. This condition does not comply with NFPA 96, 2011, 6.2.4.2 and 6.2.5

B. On 06/14/17 at 1:20 pm while accompanied by the DoF, the kitchen hood contains what was described as gas pipe running across the width of the hood on one side. It did not appear that the gas pipe which feeds equipment on the opposite side of the hood is connected to the Ansul fire suppression system. There is a valve on the other side which did not appear to be linked to the Ansul for shut off. This condition does not comply with NFPA 96, 2011 10.4.

Based on direct observation the building's fire alarm system is not installed in accordance with Code requirements. Failure to properly install components of a fire alarm system may compromise the operation of the system. The system may fail to provide an effective warning if there is a fire/smoke event.

The finding is:

On 06/14/2017 at 11:40am while accompanied by the DoF, it was observed that the smoke detectors located in the "Old O.R." area were mounted to ceiling tiles however the remaining suspended ceiling was missing which does not comply with NFPA 72-2010, 17.7.3.2.1.

Based on direct observation the facility failed to provide properly ventilated hazardous areas. The condition of a large amount of oxidizing gas in a confined area, could lead to an acceleration of a fire event. This deficient practice could affect patients, staff and visitors in the area.

The finding is:

On 06/14/2017 at 10:40 am while accompanied by the DoF, the surveyor observed a minimum of 18 "H" sized medical gas tanks (approximately 190 c.f.) and 9 "E" sized tanks (approximately 25 c.f.) within the medical gas manifold room. The amount of medical nonflammable gas exceeds 3,000 c.f. The size and type of medical gas provided does not comply with the ventilation requirements of 9-3.7.5.3. This room contained a gravity type duct which penetrated up through the building to the outside however the type of the opening did not comply with NFPA 99 2012 edition section 9-3.7.5.2.