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Based on observation the facility failed to provide properly rated fire-resistive barriers and/or self-closing and automatic latching doors in a fire barrier wall from Building 01 to Building 02. This deficient practice could affect patients, staff, and visitors, if a fire were allowed between buildings due to a deficient barrier.

Findings include:

On 01/10/23 at 9:40 AM while accompanied by GMS1, an observation revealed, that the pair of doors near the Boiler Room in the 2-hour fire wall between the buildings did not close to latch when tested on the closer. The existing condition was not in accordance with NFPA 101, Section 19.1.3.4.

Based upon observation, structural components of the building are not protected to meet the identified and required construction type. Failure to protect structural elements of the building can result in failure during a fire condition leading to premature building collapse.

The finding is:

On 01/09/2023 at 1:20 pm while in the company of the FM unprotected floor/ceiling construction containing plywood was observed. Surveyor was informed that a mezzanine is present above the corridor. The corridor is used for inpatient transport. This condition does not comply with the identified protected construction type in accordance with 19.1.6.1.
Location observed: corridor #LB0008 area across from Boiler plant's Storage room #LB0004

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the lighting provided. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

The finding is:

On 01/10/2023 at 10:50 am while accompanied by the FM, exit discharge lights were observed which the facility could not confirm to be of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 7.9.1.3.
Location observed: Exit discharge door # 1M1771 for the Outpatient Recovery discharge through reception/lounge/waiting area.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect patients, staff, and visitors by preventing those occupants from readily identifying the path to an available exit from the building during an emergency.

Finding is:

On 01/09/2023 at 2:15 pm while accompanied by the FM the Lower Level Kitchen Servery lacks designated exiting to comply with 7.10.1.5.1 and 19.2.10.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

The finding is:

A. On 01/09/2023, at 1:45pm while accompanied by the FM., observation determined that the doors to walk in freezers and coolers contain padlocks which require the use of a key or combination in order to access the units after hours. This configuration allows for unknowingly locking a person inside without any means for them to egress which does not comply with 19.2.2.2.4

Based on observation, hazardous areas are not separated from the required means of egress. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

Findings include:

B. On 01/10/2023 at 2:10pm while in the company of the FM means of egress corridors serving Outpatient recovery are being used as storage. The required means of egress is compromised due to combustible items within "alcoves" approximately 140 s.f. which do not comply with 19.3.2.1.5(7) 19.3.2.1.2, 8.4.2 requiring an enclosure and sprinkler protection.

Example locations:

1. Alcove adjacent to corridor #1M0011 (life safety floor plan)

2. Alcove adjacent to passage #1M1429 (life safety floor plan)

C. On 01/10/2023 at 9:45 am while accompanied by the FM an open 12 inch diameter duct was observed penetrating the corridor wall of the elevator machine room for Car #1 (life safety floor plan - Elev 3). It is unknown if a damper exists, is abandoned or active, therefore the elevator machine room is open to the means of egress corridor which does not comply with 19.3.2.1.5 (7) NFPA 80-2010, 19.2.3. Further it is unknown if the duct terminates into a shaft after crossing the means of egress corridor #1M0008 (life safety floor plan).

Based on observations not all enclosures of hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building due to smoke and fire passing from the hazardous area through the remainder of the building.

Findings include:

On 01/09/23 while accompanied by the GMS1 it was identified that on the First Floor, rooms were being used for storage that were not provided with a closing device on the door to protect the exit corridor in the event of a fire. This does not comply with NFPA 101, 39.3.2. Locations observed:

1. At 9:03 AM, Room 1W0122 (Former Office).
2. At 9:05 AM, Rooms 1W0101-0103 (Former offices converted into one storage space).

Based on observation during the survey walk through the facility failed to document inspection of the kitchen hood fire suppression system. This deficient practice could affect patients, staff and visitors during a fire event.

The findings include:

A. On 01/09/2023 at 2:00 pm in the company of the FM observation of the inspection tag for the grease hood fire protection system was observed. The record of the date and initials of the person completing the monthly inspection is not provided on the tag to comply with NFPA, 17, 2009, 11.2.4 / NFPA 17A, 2009, 7.2.5.

B. On 01/09/2023 at 2:10 pm in the company of the FM the location of the manual activation device for the ansul system does not comply as being within the path of exit to the designated egress door from the kitchen. This condition does not comply with 5.7.1.7 NFPA 17 2009, NFPA 17A, 2009, 5.2.1.10. The device is located on a west wall of the kitchen close to the Server and not within the current designated means of egress from the kitchen.

C. On 01/09/2023 at 2:11 pm in the company of the FM the manual actuator for the ansul system lacks identification (signage) as to the protected hazard. This condition does not comply with NFPA 17, 2009, 5.7.1.9, NFPA 17A 2009, 5.2.1.10.

Based on observation the facility failed to provide protection for the fire alarm components. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 01/10/2023 at 10:35 am while accompanied by the FM, it was observed that the fire alarm remote annunciator located in the Outpatient Lobby (not continuously staffed 24/7) was not provided with smoke detection to comply with NFPA 72, 2010, 10.15

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

Findings include:

A. On 01/10/2023 at 9:12 am while accompanied by the FM the first floor level of Stair H the top of the ladder sprinkler protection is lacking in the ceiling pocket. This condition does not comply with NFPA 13 2010, 8.6.7

B. On 01/10/2023 while accompanied by the FM sprinkler protection is lacking for the areas within Exit Stairways due to the following:

1. At 10:50 am at the bottom of the Stair A to comply with NFPA 13, 2010, 8.1.1 (3), 8.5.3.2.1, 8.8.5.2 distance from sprinklers to walls and obstructions to sprinkler discharge patterns.

2. At 9:30 am Stair F at both the top and bottom to comply with NFPA 13, 2010, 8.1.1 (3), 8.5.5.1, 8.15.3.2.1.

C. On 01/09/2023 at 1:20 pm while in the company of the FM, it was observed on the Lower Level Kitchen Freezer #8
is not provided with fire sprinkler protection to comply with NFPA 13, 2010, 8.1.1 for a fully sprinklered building.

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

The finding is:

On 01/09/23, while accompanied by the GMS1, sprinkler heads are not installed to comply with NFPA 13, 2010, 26.2. Locations observed:

1. At 1:44 PM, top level (Fifth) of Exit Stair tower #7.

Based upon observation, corridor doors are not positive latching. Failure to provide positive latching corridor doors can compromise the effectiveness of the door to remain closed to prevent the passage of smoke from one side of the corridor wall to the other.

The finding is:

On 01/10/2023 at 10:25am while in the company of the FM it was observed that pairs of cross corridor doors did not self close to the latched position to comply with 19.3.6.3.5. Location observed: 1st floor cross corridor doors from Surgery to corridors #1M1797 and #1M0006 (life safety floor plan).

Based on an observation, the facility failed to maintain the smoke barrier doors. This deficient practice could patients, staff, and visitors, if smoke from a fire was allowed to pass from one smoke compartment to an adjacent smoke zone.

Findings include:

On 01/09/23 at 2:59 PM, while accompanied by GMS1, an observation revealed that the cross corridor doors at the West/East Smoke Barrier on the First Floor near Elevator 5 did not close to a smoke tight condition in accordance with NFPA 101, 2012 Edition, Section 19.3.7.8.

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

The finding is:

On 01/10/2023 at 11:15 am in the company of the FM, it could not be confirmed through observation and staff interview whether the outlets located in the anesthesia work room were being utilized. Further discussion did not indicate if the outlets (oxygen and vacuum lines) had been utilized for instrument or medical purposes. The surveyor was informed that the outlets do utilize the same compressor as outlets for patient respiration. This is not in compliance with NFPA 99, 2012, 5.1.3.9.2.1.

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

The finding is:

A. On 01/09/2023 at 2:15 pm in the company of the FM, it could not be confirmed through observation and staff interview that electrical bonding of the facility's medical gas piping systems has been completed. This was confirmed within the medgas manifold room adjacent to the loading dock. This is not in compliance with NFPA 70, 2011, 250.104 (B)







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B. On 01/09/2023 at 2:00 pm in the company of the E, it could not be confirmed through observation and staff interview that electrical bonding of the facility's medical gas piping systems has been completed. The surveyor did not observe evidence of bonding of the medical gas piping and vaccum equipment located on the 6th floor in Mech 6M6044. This is not in compliance with NFPA 70-2011, 250.104 (B)

Based on observations and interviews, the facility failed to install and maintain a compliant electrical system. This deficient practice could affect patients, and staff if the emergency power failed to transfer back to normal power due to a transfer switch failure.

Findings include:

On 1/10/2023, at 10:30am while accompanied by GMS2 it was determined by visual observations that CathLab 10 and Procedure 14, both located in the Cathlab Suite, were not installed with normal power outlets as required by NFPA 70-2011, 517.19.

Based upon 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:

A. On 1/9/2023 at 1:57pm, while in the company of the E, it was observed that an electrical receptacle on the 6th floor in toilet room 6M6037 is not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(1).

B. On 1/9/2023 at 2:30pm, while in the company of the E, it was observed that an electrical raceway on the 5th floor in Nurse's Station 5M0569 is within 6ft of a sink and not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B)(5).

Based upon observation, not all portions of the electrical system are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because electrical systems could fail to operate properly when needed if they are not properly installed.

Findings include:

On 01/09/23 at 1:45 PM, while accompanied by the GMS1, it was observed that an electrical junction box in the IT Closet on the Fifth Floor was missing a cover plate. Therefore, the electrical system is not in compliance with NFPA 70-2011, 314.28©.