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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 concerns the fire resistant rating of the structure. Failure to maintain fire rated structural assemblies could affect patients, staff and visitors within a means of egress if fire compromised the structural integrity of the building.

Findings are:

A. While accompanied by the FM, the surveyor finds that the provider is not able to demonstrate that the facility complies with the minium construction type requipments to comply with 19.1.6.2 for a Type II (222) Construction (as defined by NFPA 220) due to following:

1) The open web steel joists (bar joists) supporting the concrete metal deck are unprotected.

2) The monolithic gypsum board ceiling tied to the floor joists which comprises a floor/ceiling assembly is compromised by containing large holes or is missing.

3) The provider lacks documentation that demonstrates how the above complies as a required two hour fire rated floor/ceiling assembly.

Example locations observed:
On 08/28/2023 at 3:10 PM North Wing 4th floor
On 08/29/2023 at 10:10 AM West Wing 2nd floor

B. On 08/29/2023 at 10:19 AM while accompanied by the FM, the surveyor finds that the provider failed to maintain a fire resistive construction for structural members. Location observed: 2nd floor North Wing near the two hour barrier and Room CTR MCC. The beam runs perpendicular to the two hour barrier and lacks fire proofing at the bottom flange.

Based upon observation, stairs are not constructed to maintain a fire/smoke tight separation. Failure to provide a continuous protected enclosure may affect visitors, staff and patients from a safe evacuation during a fire event.

The Finding is:

On 08/29/2023 at 1:13pm while accompanied by the FM, the surveyor observed a door to an exit stair enclosure which does not latch upon closing to comply with 8.3.3.1, NFPA 80, 2010. location observed:
2nd floor West Wing Exit Stair across from elevators.

Based on direct observation the facility failed to provide exit stairways enclosed with construction having the proper fire resistance rating. This deficient practice could affect patients, staff, and visitors if fire and smoke were to enter the exit enclosure and encumber evacuation of the facility during a fire emergency.

The findings are:

On August 28, 2023, the following deficiencies were observed:

A. At 1:25pm it was observed in the company of the CE that door serving the Sixth-Floor Southeast Exit Stair enclosure of Building "D" did not latch upon closing to comply with 8.3.3.1 and NFPA 80-2010.

B. At 3:00pm it was observed in the company of the CE that door serving the First-Floor Southeast Exit Stair enclosure of Building "A" did not latch upon closing to comply with 8.3.3.1 and NFPA 80-2010.

Based on observation, not all designated fire/smoke barriers are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors on the building because fire could pass between adjacent fire compartments if fire barriers are not properly constructed.

The finding is:

On 08/29/2023 while accompanied by the FM a 2-hour rated fire/smoke barrier was observed which contains windows on both sides of the barrier. The windows are located less than 24" from the adjacent exterior building wall which also contains windows at a 90 degree angle. The exterior building walls contain patient room windows, office windows and windows to hazardous areas (4th floor) less than 30" from the adjacent wall. The angle of exposure being less than 180 degrees does not provide protection on either side of a fire/smoke compartment. This does not comply with 8.3. Either exterior walls do not comply with 7.2.2.5.2.1 and 7.2.2.5.2.2 for a minimum 10'-0".

Locations observed:

1. At 10:05 AM 4th floor walls between the North and West Wings.
2. At 10:50 AM 3rd floor walls between the North and West Wings.
3. At 11:15 AM 2nd floor walls between the North and West Wings.
4 At 1:30 AM 1st floor walls between the North and West Wings.

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.

Findings include:

On 08/29/2023 at 1:30 PM while in the company of the FM an exterior means of egress was observed in which the path is nonreliable. Location observed: North Wing exit discharge vestibule with exterior stair. The means of egress does not comply with 19.2.7 and 7.7.3.2 due to the following:

1. The discharge door from the Vestibule does not appear to be maintained and does not comply with the requirements of 7.2.1.4.5.1 for the minimum force applied.

2. The walking surface of the exterior stair to the public way does not comply with 7.1.6.2 and 7.1.6.3 for a walking surface that is reliable.

Based upon observation, vertical openings are not constructed and maintained to provide separation of floor levels in accordance with requirements. This deficient practice could affect patients, staff and visitors if a failure to protect vertical openings would permit the effects of a fire/smoke to expose and compromise the safety of occupants on different floor levels.

The findings include:

A. On 08/28/2023 at 9:50 AM while accompanied by the FM the surveyor finds that the provider utilizes induction type units on all floor levels in patient care and staff areas. The units contain approx 3 inch diameter sheet metal ducts of unknown guage penetrating shaft/chases without dampers. The facility lacks accurate and detailed information to include the fire rating of the shaft/chases in compliance with NFPA 90A - 2012, 5.3.2. 5.3.3, 5.4.1.
Example location observed: 4th floor North Wing

B. On 08/28/2023 at 1:25pm while accompanied by the FM a shaft wall was observed which is 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. The shaft is not complete to the deck above. Location observed: 4th floor North Wing office closet.

Based on direct observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate hazardous areas from required means of egress paths can compromise the safety of occupants during a fire emergency.

The findings are:

On August 28, 2023, the following deficiencies were observed:

A. At 1:50pm it was observed in the company of the CE that the Fifth-Floor corridors in Building "D" contained large amounts of combustible materials that are not separated from the means of egress by construction capable of resisting the passage of smoke to comply with Section 19.3.2.1.2 and 8.4.

B. At 2:00pm it was observed in the company of the CE that the Fourth-Floor corridors in Building "D" contained large amounts of combustible materials that are not separated from the means of egress by construction capable of resisting the passage of smoke to comply with Section 19.3.2.1.2 and 8.4.

C. At 2:23pm it was observed in the company of the CE that the Third-Floor North Elevator Lobby of Building "D" contained large amounts of combustible materials that are not separated from the means of egress by construction capable of resisting the passage of smoke to comply with Section 19.3.2.1.2 and 8.4.

D. At 3:30pm it was observed in the company of the CE that the self-closing door serving the Storage Room from the Kitchen was propped open by a food service cart and therefore is not separated from the remainder of the occupancy by construction capable of resisting the passage of smoke to comply with Section 19.3.2.1.3 and 8.4.3.5.

Based on observation the facility failed to provide exhaust ducts as required by code. This deficient practice could result in the uncontrolled spread of fire and products of combustion during a kitchen hood/duct fire event, which may affect patients, staff and visitors.

The finding is:

On 08/29/2023 at 10:05 AM while accompanied by the FM, through observation and staff interview the kitchen grease hood exhaust duct does not comply with the following per NFPA 96, 2011:

1. The access panel provided does not comply with 7.4.3.1, 7.4.3.2

2. The acces panel lacks signage to comply with 7.1.6.

3. The horizontal duct run lacks a fire rated enclosure to separate it from hazardous areas (storage rooms) to the exterior wall in order to comply with 7.7.1.1.

4. The horizontal duct run lacks openings at changes in direction to comply with 7.3.1.

Based on observation, not all portions of the building's fire alarm system are installed to provide a manual means of activation. This deficient practice could affect patients, staff, and visitors in the building because they could be unaware of a fire condition if the fire alarm system is not properly installed.

The finding is:

On 08/29/2023, at 9:45 AM while accompanied by the FM observation determined that a second means of egress from the 4th floor East Wing is at the South East stair. There is no manual fire alarm activation station at the location to comply with 19.3.4.2.1 and 9.6.2.3.

Based on direct observation, and interview, the facility failed to maintain a compliant fire alarm system. This deficient practice could affect patients, and staff if the fire alarm system failed to properly notify occupants and first responders of an emergency event.

The finding is:

On August 28, 2023, at 3:45pm it was observed in the company of the CE that the fire alarm control panel in the Sub-Basement showed 5 "Trouble" codes that could not be reset to read "Normal". The FM and CE were aware of the problem and mentioned during staff interview that this is due to heat detectors in those locations malfunctioning because of the high temperatures incurred over the last week. This is not in compliance with compliance with NFPA 72-2010, 10.12., 14.2.1.2.2.

Based on observation, the facility failed to provide a complete automatic sprinkler system where installed. This deficient practice could affect patients, staff, and visitors in the building because the automatic sprinkler system may fail to extinguish a fire if it is not properly installed.

The finding is:

While accompanied by the FM the surveyor observed areas which lacked complete sprinkler protection to comply with NFPA 13, 2010 for a fully sprinklered building. Locations observed:

1. On 08/28/2023 at 2:31 PM East Wing 4th floor Storage/Facility Staff Office, ceiling area above 3 lockers.

2. On 08/28/2023 at 2:45 PM East Wing 4th floor South/East Exit Stair ceiling area near stair entry door.

3. On 08/29/2023 at 1:31 PM North Wing 1st floor North Exit Vestibule adjacent to Rehabilitation offices.

4. On 08/29/2023 at 10:56 AM based upon staff interview held in the Basement elevator equipment area, determined that it is unknown if the hoistway pits for the hydraulic elevators are sprinkler protected.

Based on direct observation, the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff, and visitors.

The findings are:

A. On August 28, 2023, at 1:30pm it was observed in the company of the CE that Mechanical Penthouses lack fire sprinkler protection. Sprinkler piping was observed but heads were not present. FM indicated that the sprinkler heads have been removed and plugged due to freezing issues. This installation is therefore not in compliance with NFPA 13-2010, 8.1.1.

B. On August 28, 2023, at 1:45pm it was observed in the company of the CE that several ceiling tiles were removed from the Fifth-Floor of Building "D" which would allow heat and products of combustion to bypass the installed sprinkler head. This installation is therefore not in compliance with NFPA 13-2010, 8.6.4.1.1.

Based on observation and document review, the sprinkler system is not being inspected, tested and maintained in accordance with Code requirements. Failure to properly inspect, test and maintain the sprinkler system can result in failure of the system to operate as required when needed to control a fire event.

Findings include:

On 8/28/2023, at 1:35 pm while in the company of the FM, it was observed that the documentation for the Weekly Fire Pump Visual Inspection in accordance with 2011 Edition of NFPA 25, Section 8.2.2, and Table 8.1.1.2, is not available for review.

Based upon observation, corridor doors are not positive latching. Failure to provide positive latching corridor doors can compromise the effectiveness of the door as a means of egress from the room to the corridor. This deficient practice can affect patients, staff and visitors from gaining access to a means of egress corridor.

The finding is:

On 08/29/2023 at 1:45 PM while accompanied by the FM, it was observed that corridor doors were equipped with an additional hasp type lock on the corridor side. This does not comply with 19.3.6.3.5 for a corridor door which is required to have a means for keeping the door in the closed position (latched not locked). Closing and latching the door requires several operations rather than one motion which does not comply with 7.2.1.5.3 and 7.2.1.5.10.2.
Locations observed: 1st floor West Wing patient rooms

Based upon observation, fire/smoke barrier walls are not maintained to afford the required/indicated hourly protection rating. This deficient practice could affect, patients, staff and visitors if a failure to maintain fire/smoke barrier wall construction can result in the spread of fire/smoke condition to adjacent zones intended to function as areas of refuge for building occupants

The finding is:

On 08/28/2023 at 1:54 PM while accompanied by the FM, observation determined that elevator doors are located within a designated smoke barrier. This condition does not comply with 8.5.6.2 for the requirements of smoke barrier doors. Elevator doors are not sealed against the passage of smoke as required by 8.5.6.2 and do not meet the requirements of UL1784 for air leakage.

Location observed:
Designated smoke barrier (shown on 2018 Life Safety floor plans) between West Wing and East Wing all levels.

Based on observation the facility failed to protect elevator equipment. This deficient practice could result in the elevator power not being shut down prior to sprinkler activation in the event of a fire in the elevator shaft.

The finding is:

On 08/29/2023 at 10:56 AM while accompanied by FM, observation revealed the facility failed to provide a heat detector within 2-feet of a sprinkler head in the room location occupied by the elevator equipment for both elevator #1 and #2. This condition does not comply with 19.5.3, ANSI A17.1, 2007, 2.8.3.3.2 and NFPA 72, 2010 Edition 21.4.2.

Based upon document review, fire drills are not being conducted in accordance with Code requirements. Failure to conduct and document fire drills can compromise the safety of any building occupants during emergency evacuation.

Findings include:

On 8/28/2023, at 1:15 pm while in the company of the FM, it was observed that the documentation of acknowledgment regarding signal receipt by the Fire Department or monitoring agency is not available in accordance with Section 19.7.1.4 through 19.7.1.7.

Based upon document review, fire drills are not being conducted in accordance with Code requirements. Failure to conduct and document fire drills can compromise the safety of any building occupants during emergency evacuation.

The finding is:

On 8/29/2023, at 1:20 PM while in the company of the FM, it was observed that the documentation of acknowledgment regarding signal receipt by the Fire Department or monitoring agency is not available in accordance with Section 19.7.1.4 through 19.7.1.7.

Based on observation and document review, fire and smoke doors are not maintained in accordance with Code requirements. Failure to conduct and document fire and smoke door inspection and maintenance can compromise the safety of any building occupants if the door assemblies are not maintained as intended to restrict the spread of fire & smoke during a fire emergency.

Finding include:

On 8/28/2023, at 1:45 pm while in the company of the FM, it was observed that the documentation for Annual Fire and Smoke Door Inspections in accordance with Section 21.7.6, 8.3.3.1, 7.2.1.15, and 2010 Edition of NFPA 80, Section 5.2.4.2 was not performed per code requirements.

Based on observation and document review, fire and smoke doors are not maintained in accordance with Code requirements. Failure to conduct and document fire and smoke door inspection and maintenance can compromise the safety of any building occupants if the door assemblies are not maintained as intended to restrict the spread of fire & smoke during a fire emergency.

The finding is:

On 8/29/2023, at 1:55 PM while in the company of the FM, it was observed that the documentation for Annual Fire and Smoke Door Inspections in accordance with Section 21.7.6, 8.3.3.1, 7.2.1.15, and 2010 Edition of NFPA 80, Section 5.2.4.2 was not performed per code requirements.

Based on observation and staff interview, the facility lacks complete electrical bonding of the medical gas piping system. Failure to install and maintain this installation could potentially result in the piping system becoming electrically energized. This deficient practice could affect patients, staff and visitors.

The finding is:

On 08/29/2023 at 2:45 PM am while in the company of the FM, it could not be confirmed through direct observation and staff interview that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with 2011 Edition of NFPA 70, Section 250.104 (B).

Based on direct observation medical gas system piping is not installed and maintained in accordance with Code requirements. Failure to install piped medical gas systems in accordance with requirements can cause disruption of services or add to the severity and progression of fire throughout the facility.

Findings include:

On August 28, 2023, at 1:45pm it was observed in the company of the CE that medical gas system piping above the ceiling near the First Floor Nurse's Station in Building "A" is supported by a dissimilar metal and not insulated to comply with NFPA 99-2012, 5.1.10.11.4.4.

Based on observation, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

The finding is:

On 08/29/2023 at 11:35 AM while in the company of the FM, the surveyor observed that a critical care patient area , lacks electrical receptacles served by normal power to comply with NFPA 70-2011, 517-19(A).
Location observed: East Wing 2nd floor Procedure Room

Based on direct observation not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients if power serving electrical equipment required for patient care were unavailable during and/or after an emergency event.

The finding is:

On August 28, 2023, at 2:45pm it was observed in the company of the CE that all receptacles in the O.R. are fed from the same isolation panel. Therefore, the O.R. lacks electrical receptacles served by normal power to comply with NFPA 70-2011, 517-19(A).