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Based on observation and staff interview, the egress doors are not installed in compliance with code requirements. If egress components fail in the event of an emergency, then all occupants' safety is at risk.

The finding is:

On 3/278/23 at 3:00pm while in the company of DOF the Delayed-Egress Locking System installed on exit doors on the 6th floor were not verified to be reset by manual means only. On 3/28/23 at 10:00am it was determined that the key required to manually reset the assemblies could not be located by facility staff.

Based upon observation, stairways are not maintained in accordance with code requirements. Failure to maintain code compliant stairways can impair building occupants' use of the stair for egress from the building during a fire/smoke event.

The finding is:

On 3/27/2023 at 1:30pm while in the company of the DOF and HTSE it was observed that the stairs between 11th and 12th floors lacked guard railings that restricted passage of a 4" sphere to comply with 7.2.2.4.5.3. The stair runs are noted to be several feet apart horizontally, which is greater than the 12" horizontal distance permitted by CMS for approved existing stairs to permit open guards.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material and block exiting.
The findings are:

On 3/27/2023, while in the company of the DOF and HTSE, it was observed that spaces are used for the storage of combustible materials which 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.
A. at 1:20pm on the 12th floor in the corridor north of stair #3 (Corr. 1201H)
B. at 1:50pm on the 11th floor in Pat. Rm. 11-015

Based on document review and observation, it was determined that the facility failed to properly manage and maintain the existing Air-conditioning and Ventilating Systems. This deficient practice could affect patients, staff and visitors if components of the system build up with dust in quantities deemed hazardous which may contribute to the systems failure to limit the spread of fire/smoke during a fire event.

Finding include:

On March 27, 2023, at 1:30 pm while in the company of the COO and OMF, it was observed that the Fusible Link Fire Dampers Inspections as required by 2010 NFPA 80, 19.4.1.1 was performed. However the Fusible Link Fire Dampers Inspections summary indicated deficiencies which have not been corrected at the time of the survey.

Based on direct observation the facility failed to correctly separate components for the elevator systems. This deficient practice could affect patients, staff and visitors, if during a fire event, there is a failure to separate areas dedicated to the function of the elevators, then there is potential for a malfunction or delayed use of the elevators by the fire department.

The finding is:

On 3/27/23 at 1:00pm while accompanied by the DOF and HTSE, the elevator machine room in the mechanical penthouse was observed in use as a place for storage of combustible materials not directly related to the function of the space, and therefore does not comply with Section 9.4.2.2, ANSI/ASME A17.3 2008 edition, section 2.2.1.

Based on document review and observation, 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 March 27, 2023, at 1:51 pm while in the company of the COO and OMF, it was observed that the documentation for Annual Fire and Smoke Door Inspections were not performed in accordance with Section 19.7.6, 8.3.3.1, 7.2.1.15, and NFPA 80-2010, Section 5.2.4.2. Also, Annual Fire and Smoke Door Inspections summary indicated deficiencies which have not been corrected at the time of the survey.

Based on observation and staff interview during the building tour the facility lacks complete protection of the medical gas piping system. Failure to install and maintain this installation could result in failure of the piping system. This deficient practice could affect patients, staff, and visitors.
The finding is:

On 3/28/2023, at 2:00pm while in the company of the DOF, OMF, and HTSE, it could not be confirmed through direct observation upon conclusion of the walk-through portion of the survey that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with NFPA 70-2011, 250.104 (B).

Based upon observation and staff interview, 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 3/28/2023, at 1:10pm while in the company of the DOF and HTSE, it was observed in the mechanical penthouse that an electrical receptacle in the toilet room is not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(1).