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During the survey walk-through while accompanied by the facility representative it was observed that components of the buildings designated construction type do not comply with, 19.1.6.2, and NFPA 220, 1999 Edition. This condition could affect individuals on the floor of fire incident from safely finding the exit location.
Findings include:
A. 01/22/2015 at 2:00 pm 1st floor Stair # 6 it was observed that a structural steel beam is partially exposed which forms part of a lintel structure stretching across the landing of an exit stair. Location observed is above the ceiling halfway between a pair of aluminum control doors and the discharge door.

A. Based on direct observation and document review with the Facility representatives on 01/21/15, the surveyor observed that patient care areas are not separated from means of egress corridors which does not comply with 19.3.6. Lack of properly separated patient care areas from means of egress corridors could result in the inability of staff to confine a fire/smoke event and effectively evacuate patients from the area.

Findings include:

1. At 10:30AM on 01/21/2015 while accompanied by the facility representatives, 2nd Floor, One-Day Surgery / Recovery South Pavilion: is not a designated suite (not shown on the Life Safety floor plans). This area contains patient care bays with privacy curtains which are open to the means of egress corridor. This condition does not comply with 19.3.6.1 exception 1(a).

2. At 10:50AM on 01/22/2015, the 1st floor Emergency Department was observed to have exam rooms open to the corridor (non smoke tight curtains provided). This constitutes a patient care area open to the corridor. These areas do not comply with 19.3.6.1, Exception 1 (a).



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B. Based on observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the locations, as well as any staff and visitors present, because the lack of smoke detectors leaves the exit access corridors unprotected against early and prompt notification of a fire event that could render the exit access corridors unusable.

Findings include:

1. At 10:20am on 01/22/2015, 1st floor radiology/imaging area was observed to have dressing - waiting areas open to the corridor (non smoke tight curtains provided) which are not staffed 24/7. These areas are not otherwise provided with smoke detection to comply with 19.3.6.1, Exception No. 1 (c).

Based on observation during the survey walk-through, accompanied by facility staff, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke to enter the egress corridor.

Findings include:

A. At 1:35 PM on 01/21/2015, on the second floor of the North Pavilion, the work room of the Physical Therapy reception area, which is not constantly attended and which was observed to be open to the adjacent corridor, was observed to lack smoke detectors as required by Subpart (c) of Exception 1 to 19.3.6.1.

During the survey walk-through, accompanied by facility staff, it was observed that not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could compromise the use of the exit access corridor during a fire/smoke event.

Findings include:

A. At 9:50 AM on 01/21/2015 on the fifth floor of the North Pavilion it was observed that the corridor door to the north elevator lobby is not equipped with latching hardware as required by 19.3.6.3.2.

B. At 9:30 AM on 01/22/2015 during staff interview it was learned that corridor doors that are equipped with an electric strike are programmed to fail open thus leaving the doors without positive latching hardware as required by 19.3.6.3.2. Examples include Clean Utility N3749 and Sleep Suite N3727B.

C. At 10:42 AM on 01/21/2015 on the third floor of the North Pavilion it was observed that the corridor door to Office N3714 has abandoned holes drilled through the door.

D. At 11:02 AM on 01/21/2015 on the second floor of the North Pavilion it was observed that the corridor doors to the Chapel are not equipped with latching hardware as required by 19.3.6.3.2.

Based on observation during the survey walk through with the Maintenance Supervisor and a maintenance staff present the surveyor finds that designated two fire rated enclosures are not protected in accordance with 8.2 of NFPA 101 - 2000 and/or NFPA 90A - 1999. These deficiencies could affect any patients, as well as any staff and visitors because the failure to provide dampers and proper installation of shaft could result in smoke or fire passing from one part of the building to another in a fire emergency.

Findings include:

A. At 1:15PM on January 21, 2015, designated two hour fire rated enclosure identified on the Life Safety Drawings dated 2/25/14, was observed with exhaust duct penetrations through walls which lack fire dampers in accordance with NFPA 90A.

1. South Pavilion, Third Floor: South Elevator Lobby, Electrical Closet 200.

B. At 1:35PM on January 21, 2015, South Pavilion, Second Floor, designated
two hour fire rated shaft wall near Exit Stair #2 was observed with 6"x4" opening that
is not completely sealed.

Based on observation during the survey walk-though, accompanied by facility staff, not all shafts are enclosed with fire rated construction as required by 19.3.1.1. This deficiency could affect patients, staff and visitors in the event of a fire on a different floor.

Findings include:

A. At 9:14 AM on 01/21/2015, on the sixth floor penthouse of the North Pavilion, it was observed that there is an abandoned, uncovered electrical box located in the east fire rated wall of the south stair.

Based on observation during the survey walk-through, exit signs were not fully visible to designate the path of egress in all cases to comply with 18.2.10.1. and 7.10. 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 utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. On 01/21/2015 at 9:10am East/West corridor between the West Pavillion and the South Pavillion is not provided with visible exit signage within this corridor viewing toward the Outpatient Women's Center.

B. On 01/21/2015 at 10:10am 1st floor, Stair # 4 is not provided with visible exit signage within this stair viewing when coming from floors above or from corridor door.

C. 01/21/2015 at 11:45pm 1st floor East/West corridor adjacent to Womens Outpatient center was observed to lack a means to identify both egress paths in order to comply with 18.2.5.9.






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Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. and 7.10. 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:

A. Exit signs are not provided to identify the 2nd means of egress from corridors to the adjacent compartment to comply with 19.2.5.9. Locations include:

1. At 9:45AM on 01/21/15, Third Floor, the link between the POB and the
South Pavilion lack exit signage.

2. At 1:45PM on 01/21/15, it was observed that the Second Floor -OR corridors lack exit signage(s).

3. At 11:45PM on 01/22/2015 1st floor East/West corridor adjacent to Outpatient Lab was observed to lack a means to identify both egress paths in order to comply with 19.2.5.9.

4. At 10:52 AM on 01/22/2015, on the first floor of the South Pavilion, the east end of the main corridor connecting the main entry and the Women ' s Center was observed to be a required path of egress yet is not provided with exit signage as required by 19.2.10.1.

5. At 11:07 AM on 01/22/2015, on the first floor of the South Pavilion, the cross corridor doors located in the corridor outside the Financial Counselors ' Office were observed to be in a required path of egress yet are not provided with exit signage that will identify the path of egress when the doors are closed. 19.2.10.1.

B. Exit signs are being obstructed by other facility components and do not comply with 7.10.1.7.

1. At 10:10AM on 01/21/15, facility sign by the Southwest Nurse Station of the Med/Surge Unit and Northeast Nurse Station, Fourth Floor - South Pavilion.

During the survey walk-through, accompanied by facility staff, it was observed that paths of egress are not identified by exit signage in accordance with 19.2.10.1 and 7.10. These deficiencies could affect all patients, staff, and visitors in the areas described by preventing those occupants from readily identifying the path of egress.

Findings include:

A. At 10:05 AM on 01/21/2015, on the fifth floor of the North Pavilion, the cross corridor doors adjacent to the nurses ' station at the south end of the west corridor were observed to be a required path of egress yet are not provided with exit signage as required by 19.2.10.1.

B. At 10:45 AM on 01/21/2015, on the third floor of the North Pavilion, conflicting signage reading " Exit " and " No exit " were observed on the south exit access door from the Sleep Suite into the Pediatrics Department. 19.2.10.1, 7.10

C. At 1:16 PM on 01/21/2015, on the first floor of the North Pavilion, the south end of the corridor adjacent to the Human Resources Waiting Room was observed to be a required path of egress yet is not provided with exit signage as required by 19.2.10.1.

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During the survey walk-through, accompanied by facility staff, it was observed that not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2. These deficiencies could affect all patients, staff, and visitors within the smoke compartment of the location by allowing smoke and fire to escape from hazardous rooms into the exit access corridor.

Findings include:

A. At 9:12 AM on 01/22/2015, in the basement of the South Pavilion, a 6 inch diameter unsealed penetration was observed in the fire rated wall between the Maintenance Shop and the Fire Pump Room.

B. At 9:37 AM on 01/22/2015, in the basement of the South Pavilion, the IT Room located behind the north bank of elevators was observed to be used for combustible storage. The door to this room was observed to lack hardware to make the door self closing as required by 19.3.2.1.

C. At 10:40 AM on 01/22/2015, on the first floor of the South Pavilion, the X Ray Storage Room S1263E was observed to be used for combustible storage. The door to this room was observed to lack hardware to make the door self closing as required by 19.3.2.1.

D. At 1:45PM, on 01/21/2015 in the Second Floor of South Pavilion, it was observed that the arrangement of the corridor pair of doors to Storage Room S2358 room do not comply with 7.2.1.5.5 because of the inactive leaf that is not self-closing to latched condition. The arrangement does not comply with 7.2.1.5.5 because the inactive leaf can be mistaken as an active leaf and cannot be opened without first opening the active leaf.

E. At 9:50AM, on 01/21/2015 in the 4th Floor of South Pavilion, - The door to the designated two hour fire wall of the Communication Closet/ Storage Room lacks self-closing hardware to comply with NFPA 2000 19.3.2.1.

F. At 10:55AM on 01/21/15 it was observed that the door to Storage Room S4376 in the Fourth Floor of South Pavilion was self-closing but does not latch all the way to the frame to comply with 8.2.3.2.3.1(2).

Based on observation during the survey walk-through,while accompanied by facility representatives not all hazardous areas are separated from the remainder of the building to comply with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. At 1:30pm on 01/21/2015 Lower level medical records room combined with general storage as indicated on the facility life safety floor plans as 1-hour enclosed. It was observed that two of the four entry doors are not identified as fire resistant due to the lack of a label.



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B. At 2:10 PM on 01/21/2015, in the basement of the North Pavilion, the inactive leaf of the fire rated door at Engineering Shop NL729 was observed to be caught on the concrete floor and held open.

C. At 2:20 PM on 01/21/2015, in the basement of the North Pavilion, the door to Marketing Storeroom NL749 was observed to not be equipped with positive latching hardware as required by 19.3.2.1.

Based on observation with the Director of Facilities and the HVAC staff present on 08/11/2014, the surveyor observed that hazardous areas are not enclosed to comply with 18.3.2. Lack of proper enclosure of a hazardous area could result in a fire/smoke event within the means of egress corridor preventing access to the adjacent smoke compartment.

Findings include:

A. 01/21/2015 at 10:00am 1st floor, CO2 Storage room, indicated to have a 2-hour fire resistant rating contains a PVC pipe run which is open to the room at one end and penetrates the 2-hour wall enclosure at the other.

B. 01/21/2015 at 1:00pm 1st floor, labeled fire supression room contains several pipe penetrations through the corridor wall which are not sealed against the passage of smoke.

Based on observation during the survey walkthrough not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This condition may affect patients, staff and visitors on the upper floors from a safe means of egress during a fire/smoke event.

Findings include:

A. 01/21/2015 at 10:15am 1st floor Exit Stair # 2 a designated 2-hour enclosed/separated Exit stair is not separated to comply with 19.3.1.1, 7.1.3.2.1 (e)Conditions observed include:

1. conduit runs from an adjacent vertical shaft to the 1st floor elevator lobby area.

2. pipe runs from an adjacent vertical shaft to the 1st floor elevator lobby area.

B. At 10:20AM on 01/21/2015, 4th floor Exit Stair # 3 a designated 2-hour enclosed/separated Exit stair is not separated to comply with 19.3.1.1, 7.1.3.2.1 (e)Conditions observed include:

1. Holes around sprinkler pipe runs from an adjacent corridor to the exit Stair
that are not fire sealed.

C. At 10:40AM on 01/21/2015, 4th floor Exit Stair # 4 a designated 2-hour enclosed/separated Exit stair is not separated to comply with 19.3.1.1, 7.1.3.2.1 (e)Conditions observed include:

1. Conduit Penetration through Exit Stair #3 from access corridor wall that is not fire
sealed.









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Based on observation during the survey walk-through, accompanied by facility staff, not all stair used as exits are constructed in accordance with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by creating a hazard during evacuation of the building under emergency conditions.

Findings include:

A. The distance between guardrails was observed to be in excess of 4" to comply with subpart (3) to 7.2.2.4.6 and 19.2.2.3. This condition was observed in multiple exit stairs. Example locations of Exit stair enclosures at which this condition was observed include:

1. 2:30pm 01/21/2015 Exit Stair # 8 at First floor


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2. 9:16 AM on 01/21/2015: North Pavilion South Exit Stair No. 6.
3. 9:52 AM on 01/21/2015: North Pavilion North Exit Stair No. 5.

Based on observation with the Facility representatives, the surveyor finds that not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 9:55 AM on 01/21/2015, on the Third Floor of South Pavilion, it was observed that signage is not provided at this level inside the stair, identifying which floors are locked against re-entry and where the exit stair discharge is in accordance with 7.2.1.5.2.

B. At 2:30 PM on 01/21/15, on the Second Floor of South Pavilion, The ICU Suite configuration and the arrangement of the southwest exit access corridor for the adjacent Cancer Center, created a dead end corridor of excessive length. This condition does not comply with 19.2.5.10.

C. At 10:20 AM on 01/22/2015, on the first floor of the South Pavilion, it was observed that Stair 1 is not equipped with an interrupter gate which would prevent occupants leaving the building from inadvertently traveling to the basement instead of to the exit discharge. 7.7.3



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During the survey walk-through, accompanied by facility staff, it was observed that exit access is not arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the building.

Findings include:

A. At 11:08 AM on 01/21/2015, on the second floor of the North Pavilion, the pair of cross corridor doors located by the south elevators are provided with exit signage. One leaf is equipped with manual flush bolts, which would entail more than one operation to open.

During the survey walk-through, accompanied by facility staff, it was observed that exit access is not arranged so that exits are readily discernable at all times in accordance with 18.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to choose the proper path of egress.

Findings include:

A. Exit signage was observed to be placed over what appear to be control doors which are locked at night against entry from elevator lobbies into various patient areas. Travel distance within the lobby appears to comply with 18.2.5.10, so these doors are not in a required means of egress from the lobby side. Egress from the patient areas is always available. Locations include:

1. Commencing at 2:24 PM on 01/20/2015, on floors 4 through 7 in the West Pavilion, both the north and south elevator lobbies. On floor 3, the south elevator lobby.

Based on observation during the survey walk-through while accompanied by the Facilities Representative not all designated suites comply with 19.2.5 concerning the remotely located exit access doors. This condition may affect patients, staff and visitors during a fire emergency by increasing the amount of time and travel distance required to reach an exit access corridor.

Findings include:

A. On 1/22/2015 at 1:30pm, First floor Outpatient Lab, the travel distance from the most remote exam room to the means of egress corridor does not comply with 19.2.5.8 for multiple intervening rooms having a travel distance of 50' or less. Surveyor observed two intervening rooms (access aisle and a waiting room) with a travel distance of approximately 70' to an exit access corridor door.

Based on observation during the survey walk-through, not all exit discharge locations are provided with illumination to comply with NFPA-101, Sections 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

A. Exterior egress path was observed that is not provided with lighting, on emergency power, so that the failure of one fixture (bulb) will not leave the area in darkness to comply with 19.2.8.

Location observed:
1st floor non designated stair located in the South/East part of building adjacent to the Physical Therapy suite has no exterior lighting above the discharge door.

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

A. At 8:55 AM on 01/21/2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in South Pavilion -Elevator Lobby, Third Floor by Stairwell #1, which is located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

B. At 9:15 AM on 01/21/2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in South Pavilion - Med/Surge, Third Floor, in Clean Room 3612, which is located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

C. At 9:20 AM on 01/21/2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in South Pavilion - Med/Surge, Third Floor, in Soiled Utility Room 3614, which is located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

D. At 9:45 AM on 01/21/2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in South Pavilion, Third Floor, from POB link entrance to Mother /Baby, which is located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

E. At 8:55 AM on 01/21/2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in South Pavilion, Third Floor, Elevator Lobby, which is located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

F. At 1:30 PM on 01/21/2015 the surveyor observed that the unoccupied fire pump room in the south pavilion housed a fire alarm panel and was not equipped with a smoke detector to meet the requirements of NFPA-72, Section 1-5.6.



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Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

A. At 2:36 PM on January 20, 2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in West Building - Med/Surge, Fifth Floor exit access corridor near Soiled Holding Room W5529, which is located within
3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

B. At 2:38 PM on January 20, 2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in West Building - Med/Surge, Fifth Floor, and Room 5521 next to Medication Room W5519, which is located within
3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

Based on observation during the survey walk-through, accompanied by facility staff, the facility failed to provide a fire alarm system with approved components, devices or equipment installed according to NFPA 72. This deficiency would affect all occupants if there was a delay in the fire alarm system ' s response time during a fire.

Findings include:

A. At 9:38 and 9:55 AM, respectively, on 01/21/2015, on the fifth floor of the North Pavilion, smoke detectors were observed to be located within 18 inches of a supply air diffuser. Locations observed are at both the east and west cross corridor doors.

Based on direct observation during the survey walk-through, with the Maintenance Supervisor and staff maintenance, the surveyor find that not all portions of the building fire protection systems and materials are installed and maintained in accordance with NFPA 13 - 1999.

Findings include:

A. By direct observation 1/20/15 at 10:00 AM while in the company of the Director of Engineering / Construction,the surveyor finds the generator room is not provided with a complete sprinkler fire suppression system. NFPA 13, 1999, 1-6.1 & 13, 5-1.

B. The following rooms were observed to lack sprinkler protection:

1. 10:11 AM on 01/22/2015, in the basement of the South Pavilion: Shower Room SL275 in the Nuclear Medicine Department.
2. 10:23 AM on 01/22/2015, on the first floor of the South Pavilion: the IT closet adjacent to the Cancer Center Entry Vestibule.


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C. At 10:45AM, on 01/21/2015, sprinkler head escutcheons were observed to be missing to comply with NFPA 13-1999. Locations include:

1. Fourth Floor - Elevator Lobby.
2. Fourth Floor - Electrical Room S4381.


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Based on observation during the survey walk, while accompanied by facility staff, failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors.
Findings include:

A. By direct observation 1/20/15 at 9:00 AM while in the company of the Director of Engineering / Construction the surveyor find the Generator Room W2664 is not provided with a sprinkler fire suppression system. NFPA 13, 1999, 1-6.1 & 13, 5-1.


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B. 01/20/2015 at 2:30pm 1st floor Stair # 3 a sprinkler head is damaged within this stair which does not comply with NFPA 13, 1999 edition.

Based on observation during the survey walk, while accompanied by facility staff, failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors. The installation does not comply with NFPA 13 1999

Findings include:

A. By direct observation 1/21/15 at 1:30 PM while in the company of the Director of Engineering / Construction the surveyor find the IT / Communications and Electrical closets on 5th Floor are not provided with fire suppression. (NFPA 13, 1999, 1-6.1 & 13, 5-1.)

B. By direct observation 1/21/15 at 1:45 PM while in the company of the Director of Engineering / Construction the surveyor find the IT / Communications and Electrical closets on 4th Floor are not provided with fire suppression. (NFPA 13, 1999, 1-6.1 & 13, 5-1.)

C By direct observation 1/21/15 at 2:00 PM while in the company of the Director of Engineering / Construction the surveyor find the IT / Communications and Electrical closets on 3th Floor are not provided with fire suppression. (NFPA 13, 1999, 1-6.1 & 13, 5-1.)

D. By direct observation 1/21/15 at 2:15 PM while in the company of the Director of Engineering / Construction the surveyor find the Lower Level Morgue room NL784 that the body holding cooler is not provided with sprinkler fire protection. (NFPA 13, 1999, 1-6.1 & 13, 5-1.)

E. By direct observation 1/21/15 at 2:30 PM while in the company of the Director of Engineering / Construction the surveyor find the Electrical Room/Sub Station No. 1 room NL728 is not provided with sprinkler fire protection. (NFPA 13, 1999, 1-6.1 & 13, 5-1.)




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F. 01/22/2015 at 11:30am Lower level elevator alcove for Elevator # 1 was observed which is not provided with sprinkler protection in a building which is otherwise considered fully protected.

Based on direct observation during the survey walk-through, with the Maintenance Supervisor and staff maintenance, the surveyor find that not all portions of the building fire protection systems and materials are installed and maintained in accordance with NFPA 72. This deficiency could delayor prevent notification of a fire event to affect all patients, staff, and visitors.

A. By direct observation 1/20/15 at 10:15 AM while in the company of the Director of Engineering / Construction, the surveyor finds in Fire Pump Room (SL387), the main incoming water supply valve for the fire suppression system is not provided with tamper protection and alarm.

Based on observation during the survey walk through the surveyor accompanied by the Director of Engineering/Construction finds that fire dampers are not installed and maintained to comply with NFPA 90A . Failure to maintain fire dampers will result in failure of fire dampers in a fire emergency which could allow migration of fire and smoke to spread throughout patient areas and to multiple patient floors.


A. 6th Floor Mechanical Penthouse:
By direct observation 1/20/15 at 1:30 PM while in the company of the Director of Engineering / Construction the surveyor find the facility failed to provide a fire damper for the duct penetration from AHU 55 to the duct chase. (NFPA 90A, 1999, 3-3.4)

Based on observation during the survey walk-through, not all portions of the building trash chute system is installed in accordance with NFPA 82 1999.

Findings include;

A. 01.22.2015 at 11:00am Lower level Trash chute discharge room, the room does not maintain a required 2-hour fire resistant enclosure to comply with NFPA 82 3-2.6.1 due to the following:

1. Numerous polyvinyl chloride (PVC) pipes penetrate the floor and the walls of the room which lack the proper through wall/floor U.L. listed design.

2. A PVC pipe penetrates the 2-hour fire rated floor above and is open to the discharge room at the end of the pipe run.

3. The chute discharge room entry door does not close to latch.

4. A through wall ducted vent located above the room's entry door lacks a fire damper.

5. A partial duct penetration through the West wall of the discharge room located behind the chute's door, appears to be capped off with material that does not maintain the rooms 2-hour fire rating.

6. There is a hole through the corridor wall of the room.


B. 01.22.2015 at 11:00am Lower level electrical closet is accessed through the trash discharge room. The walls of the electrical closet (labeled 2-hour) do not maintain a 2-hour separation between the discharge room and the closet due to the following:

1. The closet walls do not continue to the underside of the floor above. The floor deck is a fluted metal deck having gaps between the top of the wall and bottom of the deck.

2. The closet wall contains an exposed wood stud at the corner.

3. The closet entry door does not maintain a 1 1/2 hour opening due to the door hardware and door frame.

4. Duct penetrations through the closet 2-hour walls lack damper installations.



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C. Doors to trash chutes were observed that did not carry a minimum fire resistance rating required by 19.5.4.1 and NFPA 82 1999 3-2.3. Locations observed include:

1. 9:23 AM on 01/21/2015, on the fifth floor of the North Pavilion in the south Housekeeping Room.

2. 10:27 AM on 01/21/2015, on the third floor of the North Pavilion in the south Housekeeping Room.

Based on observations during the survey walk-through, accompanied by facility staff, the facility failed to keep the means of egress free of obstructions and impediments to use in accordance with 7.1.10. This deficiency could affect all patients, staff, and visitors on the cited floors in the event of an emergency requiring egress or relocation.

Findings include:

A. The following exit access corridors were observed to contain idle beds, equipment, trash receptacles, etc. These items partially blocked the required clear width of the corridors:

1. 9:03 AM on 01/22/2015, in the basement of the South Pavilion: the corridor serving Stair 4.
2. 9:35 AM on 01/22/2015, in the basement of the South Pavilion: the corridor serving Stair 2.
3. 11:02 AM on 01/22/2015, on the first floor of the South Pavilion: the corridor serving the Respiratory Equipment Room S1503.

Based on observations during the survey walk-through, accompanied by facility staff, the facility failed to provide a proper storage of oxygen cylinders in accordance with NFPA 99. This deficiency could endanger staff and patients in the event of a gas related fire.

Findings include:

A. At 9:27 AM on 01/22/2015, in the basement of the South Pavilion, the light switch in Med Gas Storage SL306A was observed to be mounted less than 5 feet above the finished floor as required by NFPA 99 1999 4-3.1.1.2 (a)4.

During the survey walk through, accompanied by facility staff, it was observed that the facility failed to provide a medical gas installation that is in compliance with NFPA 99. These deficiencies could endanger patients and staff in the event of a gas system related fire.

Findings include:

A) Medical gas shut-off valves and/or alarm panels do not accurately identify the rooms or zones controlled to comply with NFPA 99, 1999. Surveyor observed this condition throughout the facility. Example location:

1) 1st floor, Cardiac Cath Lab - valve for the procedure room reads Cath Lab M34, paper sign next to valve reads zone valve rooms S1318 and S1320A, signage on the Cath Lab door reads S1318 and Cath Lab # 1, none of these match.

B) Medical gas shut-off valves are located such that there is no separation between the valve and the location of the medical gas outlets served. This condition does not comply with NFPA 99, 1999 Edition 4-3.1.2.3 (d. Location observed:

1) 1st Floor Ultrasound Suite (2,830s.f.)- There is a valve which is open to the outlets served. The prep/recovery bays contain privacy curtains. The shut off valve is located such that there is no wall intervening between the valve and the outlets served. Therefore, staff is not allowed to shut off the flow of gas without being exposed to the fire scene.

2) By direct observation 1/20/15 at 10:30 AM while in the company of the Director of Engineering / Construction, the surveyor find the medical gas zone valves (No. 37) installed for the Emergency Room are not separated from the treatment and exam rooms outlets and inlets they serve. (NFPA 99, 1999, 4- 3.1.2.3 (d)

3) By direct observation 1/20/15 at 11:00 AM while in the company of the Director of Engineering / Construction, the surveyor find the medical gas zone valves (No. 33) installed for the ICU are not separated from the patient rooms outlets and inlets they serve. (NFPA 99, 1999, 4-3.1.2.3 (d)

During the survey walk-through, accompanied by facility staff, it was observed that the generator room lacks a 2 hour fire rated enclosure as required by NFPA 99 1999 3-4.1.1.6(a). This deficiency could affect all patients, staff, and visitors in the event of a fire in the generator room.

Findings include:

A. At 9:20 AM on 01/22/2015, in the basement of the South Pavilion, it was observed that there is an unsealed pipe penetration in the fire rated east wall of the generator room.

This STANDARD is not met as evidenced by:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the
survey walk-through, the provider shall institute the appropriate Interim Life Safety Measures
until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan
of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all
such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

This STANDARD is not met as evidenced by:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute the appropriate Interim Life Safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all
such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

Based on observation during the survey walk, while accompanied by facility staff, failure to install and maintain the emergency eye wash stations could result in injury to staff under emergency use conditions. The installation does not comply with NFPA 99.

A. By direct observation 1/20/15 at 1:15 PM while in the company of the Director of Engineering / Construction the surveyor find the eye wash installed in Soiled Holding W6529 is not provided with a pressure regulating means in compliance with NFPA and ANSI Z358.1.

Based on observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the hospital if the emergency power system does not operate correctly.

Findings include:

A. On Wednesday, January 21, 2015 at approximately 10:20 A.M. the surveyor observed that the transfer switch in the electrical room on the lower level of the north pavilion served by substation #1 was serving a distribution panel that served loads from all branches of emergency power. NFPA-70, Section 517-30 requires that each branch of the essential electrical system be served by one or more transfer switches when the essential electrical system demand exceeds 150KVA.

B. On Wednesday, January 21, 2015 at approximately 10:00 A.M. the surveyor observed that the EM panel on each floor of the north pavilion was serving a mixture of life safety, critical and equipment loads. For example panel EM-60-M1 was serving mostly life safety loads, but was serving a board room heater on circuit 35. These panels were also served from a distribution panel on the lower level that was served from a single transfer switch and served all branches of emergency power.

Based on direct observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect any patient if the transfer switch serving these rooms fails.

Findings include:

A. On Wednesday, January 21, 2015 at approximately 2:00 PM the surveyor observed that the operating rooms were not equipped with normal receptacles to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

B. On Wednesday, January 21, 2015 at approximately 2:20 PM the surveyor observed that the PACU was not equipped with normal receptacles at the headwall of each bed location to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

C. On Wednesday, January 21, 2015 at approximately 1:45 PM the surveyor observed that the cab lighting for the hydraulic elevator serving the cancer center was not served from the life safety panel as required by NFPA-70, Section 517-32, and there was not a disconnect switch for cab lighting and controls within the elevator equipment room as required by NFPA-70, Section 620-22. This could affect any occupant of the building using the elevator during a power outage.

Based on observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

A. On Wednesday, January 21, 2015 at approximately 9:00 A.M. the surveyor observed that the elevator cab lights in the penthouse of the knuckle area of the north pavilion for elevators D, E, and F were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32.

B. On Wednesday, January 21, 2015 at approximately 9:45 A.M. the surveyor observed that the elevator cab lights for elevator H in the north pavilion were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32, and they were not equipped with a disconnect in the elevator equipment room in accordance with NFPA-70, Section 620-53.

Based on observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the elevators did not meet all of the requirements of ANSI/ASME A17.3. This could affect any occupants of the facility using the elevator if proper safety equipment is not installed on each elevator.

Findings include:

A. The north pavilion elevator machine room for elevator H did not have a heat detector within 2' of each sprinkler head tied to a shunt trip as required by NFPA-72, Section 3-9.4, and ASME A17.1, Section 102.2(c)(3).

During the survey walk-through while accompanied by the facility representative it was observed that components of the buildings designated construction type do not comply with, 19.1.6.2, and NFPA 220, 1999 Edition. This condition could affect individuals on the floor of fire incident from safely finding the exit location.
Findings include:
A. 01/22/2015 at 2:00 pm 1st floor Stair # 6 it was observed that a structural steel beam is partially exposed which forms part of a lintel structure stretching across the landing of an exit stair. Location observed is above the ceiling halfway between a pair of aluminum control doors and the discharge door.

A. Based on direct observation and document review with the Facility representatives on 01/21/15, the surveyor observed that patient care areas are not separated from means of egress corridors which does not comply with 19.3.6. Lack of properly separated patient care areas from means of egress corridors could result in the inability of staff to confine a fire/smoke event and effectively evacuate patients from the area.

Findings include:

1. At 10:30AM on 01/21/2015 while accompanied by the facility representatives, 2nd Floor, One-Day Surgery / Recovery South Pavilion: is not a designated suite (not shown on the Life Safety floor plans). This area contains patient care bays with privacy curtains which are open to the means of egress corridor. This condition does not comply with 19.3.6.1 exception 1(a).

2. At 10:50AM on 01/22/2015, the 1st floor Emergency Department was observed to have exam rooms open to the corridor (non smoke tight curtains provided). This constitutes a patient care area open to the corridor. These areas do not comply with 19.3.6.1, Exception 1 (a).



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B. Based on observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the locations, as well as any staff and visitors present, because the lack of smoke detectors leaves the exit access corridors unprotected against early and prompt notification of a fire event that could render the exit access corridors unusable.

Findings include:

1. At 10:20am on 01/22/2015, 1st floor radiology/imaging area was observed to have dressing - waiting areas open to the corridor (non smoke tight curtains provided) which are not staffed 24/7. These areas are not otherwise provided with smoke detection to comply with 19.3.6.1, Exception No. 1 (c).

Based on observation during the survey walk-through, accompanied by facility staff, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke to enter the egress corridor.

Findings include:

A. At 1:35 PM on 01/21/2015, on the second floor of the North Pavilion, the work room of the Physical Therapy reception area, which is not constantly attended and which was observed to be open to the adjacent corridor, was observed to lack smoke detectors as required by Subpart (c) of Exception 1 to 19.3.6.1.

During the survey walk-through, accompanied by facility staff, it was observed that not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could compromise the use of the exit access corridor during a fire/smoke event.

Findings include:

A. At 9:50 AM on 01/21/2015 on the fifth floor of the North Pavilion it was observed that the corridor door to the north elevator lobby is not equipped with latching hardware as required by 19.3.6.3.2.

B. At 9:30 AM on 01/22/2015 during staff interview it was learned that corridor doors that are equipped with an electric strike are programmed to fail open thus leaving the doors without positive latching hardware as required by 19.3.6.3.2. Examples include Clean Utility N3749 and Sleep Suite N3727B.

C. At 10:42 AM on 01/21/2015 on the third floor of the North Pavilion it was observed that the corridor door to Office N3714 has abandoned holes drilled through the door.

D. At 11:02 AM on 01/21/2015 on the second floor of the North Pavilion it was observed that the corridor doors to the Chapel are not equipped with latching hardware as required by 19.3.6.3.2.

Based on observation during the survey walk through with the Maintenance Supervisor and a maintenance staff present the surveyor finds that designated two fire rated enclosures are not protected in accordance with 8.2 of NFPA 101 - 2000 and/or NFPA 90A - 1999. These deficiencies could affect any patients, as well as any staff and visitors because the failure to provide dampers and proper installation of shaft could result in smoke or fire passing from one part of the building to another in a fire emergency.

Findings include:

A. At 1:15PM on January 21, 2015, designated two hour fire rated enclosure identified on the Life Safety Drawings dated 2/25/14, was observed with exhaust duct penetrations through walls which lack fire dampers in accordance with NFPA 90A.

1. South Pavilion, Third Floor: South Elevator Lobby, Electrical Closet 200.

B. At 1:35PM on January 21, 2015, South Pavilion, Second Floor, designated
two hour fire rated shaft wall near Exit Stair #2 was observed with 6"x4" opening that
is not completely sealed.

Based on observation during the survey walk-though, accompanied by facility staff, not all shafts are enclosed with fire rated construction as required by 19.3.1.1. This deficiency could affect patients, staff and visitors in the event of a fire on a different floor.

Findings include:

A. At 9:14 AM on 01/21/2015, on the sixth floor penthouse of the North Pavilion, it was observed that there is an abandoned, uncovered electrical box located in the east fire rated wall of the south stair.

Based on observation during the survey walk-through, exit signs were not fully visible to designate the path of egress in all cases to comply with 18.2.10.1. and 7.10. 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 utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. On 01/21/2015 at 9:10am East/West corridor between the West Pavillion and the South Pavillion is not provided with visible exit signage within this corridor viewing toward the Outpatient Women's Center.

B. On 01/21/2015 at 10:10am 1st floor, Stair # 4 is not provided with visible exit signage within this stair viewing when coming from floors above or from corridor door.

C. 01/21/2015 at 11:45pm 1st floor East/West corridor adjacent to Womens Outpatient center was observed to lack a means to identify both egress paths in order to comply with 18.2.5.9.






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Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. and 7.10. 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:

A. Exit signs are not provided to identify the 2nd means of egress from corridors to the adjacent compartment to comply with 19.2.5.9. Locations include:

1. At 9:45AM on 01/21/15, Third Floor, the link between the POB and the
South Pavilion lack exit signage.

2. At 1:45PM on 01/21/15, it was observed that the Second Floor -OR corridors lack exit signage(s).

3. At 11:45PM on 01/22/2015 1st floor East/West corridor adjacent to Outpatient Lab was observed to lack a means to identify both egress paths in order to comply with 19.2.5.9.

4. At 10:52 AM on 01/22/2015, on the first floor of the South Pavilion, the east end of the main corridor connecting the main entry and the Women ' s Center was observed to be a required path of egress yet is not provided with exit signage as required by 19.2.10.1.

5. At 11:07 AM on 01/22/2015, on the first floor of the South Pavilion, the cross corridor doors located in the corridor outside the Financial Counselors ' Office were observed to be in a required path of egress yet are not provided with exit signage that will identify the path of egress when the doors are closed. 19.2.10.1.

B. Exit signs are being obstructed by other facility components and do not comply with 7.10.1.7.

1. At 10:10AM on 01/21/15, facility sign by the Southwest Nurse Station of the Med/Surge Unit and Northeast Nurse Station, Fourth Floor - South Pavilion.

During the survey walk-through, accompanied by facility staff, it was observed that paths of egress are not identified by exit signage in accordance with 19.2.10.1 and 7.10. These deficiencies could affect all patients, staff, and visitors in the areas described by preventing those occupants from readily identifying the path of egress.

Findings include:

A. At 10:05 AM on 01/21/2015, on the fifth floor of the North Pavilion, the cross corridor doors adjacent to the nurses ' station at the south end of the west corridor were observed to be a required path of egress yet are not provided with exit signage as required by 19.2.10.1.

B. At 10:45 AM on 01/21/2015, on the third floor of the North Pavilion, conflicting signage reading " Exit " and " No exit " were observed on the south exit access door from the Sleep Suite into the Pediatrics Department. 19.2.10.1, 7.10

C. At 1:16 PM on 01/21/2015, on the first floor of the North Pavilion, the south end of the corridor adjacent to the Human Resources Waiting Room was observed to be a required path of egress yet is not provided with exit signage as required by 19.2.10.1.

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During the survey walk-through, accompanied by facility staff, it was observed that not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2. These deficiencies could affect all patients, staff, and visitors within the smoke compartment of the location by allowing smoke and fire to escape from hazardous rooms into the exit access corridor.

Findings include:

A. At 9:12 AM on 01/22/2015, in the basement of the South Pavilion, a 6 inch diameter unsealed penetration was observed in the fire rated wall between the Maintenance Shop and the Fire Pump Room.

B. At 9:37 AM on 01/22/2015, in the basement of the South Pavilion, the IT Room located behind the north bank of elevators was observed to be used for combustible storage. The door to this room was observed to lack hardware to make the door self closing as required by 19.3.2.1.

C. At 10:40 AM on 01/22/2015, on the first floor of the South Pavilion, the X Ray Storage Room S1263E was observed to be used for combustible storage. The door to this room was observed to lack hardware to make the door self closing as required by 19.3.2.1.

D. At 1:45PM, on 01/21/2015 in the Second Floor of South Pavilion, it was observed that the arrangement of the corridor pair of doors to Storage Room S2358 room do not comply with 7.2.1.5.5 because of the inactive leaf that is not self-closing to latched condition. The arrangement does not comply with 7.2.1.5.5 because the inactive leaf can be mistaken as an active leaf and cannot be opened without first opening the active leaf.

E. At 9:50AM, on 01/21/2015 in the 4th Floor of South Pavilion, - The door to the designated two hour fire wall of the Communication Closet/ Storage Room lacks self-closing hardware to comply with NFPA 2000 19.3.2.1.

F. At 10:55AM on 01/21/15 it was observed that the door to Storage Room S4376 in the Fourth Floor of South Pavilion was self-closing but does not latch all the way to the frame to comply with 8.2.3.2.3.1(2).

Based on observation during the survey walk-through,while accompanied by facility representatives not all hazardous areas are separated from the remainder of the building to comply with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. At 1:30pm on 01/21/2015 Lower level medical records room combined with general storage as indicated on the facility life safety floor plans as 1-hour enclosed. It was observed that two of the four entry doors are not identified as fire resistant due to the lack of a label.



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B. At 2:10 PM on 01/21/2015, in the basement of the North Pavilion, the inactive leaf of the fire rated door at Engineering Shop NL729 was observed to be caught on the concrete floor and held open.

C. At 2:20 PM on 01/21/2015, in the basement of the North Pavilion, the door to Marketing Storeroom NL749 was observed to not be equipped with positive latching hardware as required by 19.3.2.1.

Based on observation with the Director of Facilities and the HVAC staff present on 08/11/2014, the surveyor observed that hazardous areas are not enclosed to comply with 18.3.2. Lack of proper enclosure of a hazardous area could result in a fire/smoke event within the means of egress corridor preventing access to the adjacent smoke compartment.

Findings include:

A. 01/21/2015 at 10:00am 1st floor, CO2 Storage room, indicated to have a 2-hour fire resistant rating contains a PVC pipe run which is open to the room at one end and penetrates the 2-hour wall enclosure at the other.

B. 01/21/2015 at 1:00pm 1st floor, labeled fire supression room contains several pipe penetrations through the corridor wall which are not sealed against the passage of smoke.

Based on observation during the survey walkthrough not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This condition may affect patients, staff and visitors on the upper floors from a safe means of egress during a fire/smoke event.

Findings include:

A. 01/21/2015 at 10:15am 1st floor Exit Stair # 2 a designated 2-hour enclosed/separated Exit stair is not separated to comply with 19.3.1.1, 7.1.3.2.1 (e)Conditions observed include:

1. conduit runs from an adjacent vertical shaft to the 1st floor elevator lobby area.

2. pipe runs from an adjacent vertical shaft to the 1st floor elevator lobby area.

B. At 10:20AM on 01/21/2015, 4th floor Exit Stair # 3 a designated 2-hour enclosed/separated Exit stair is not separated to comply with 19.3.1.1, 7.1.3.2.1 (e)Conditions observed include:

1. Holes around sprinkler pipe runs from an adjacent corridor to the exit Stair
that are not fire sealed.

C. At 10:40AM on 01/21/2015, 4th floor Exit Stair # 4 a designated 2-hour enclosed/separated Exit stair is not separated to comply with 19.3.1.1, 7.1.3.2.1 (e)Conditions observed include:

1. Conduit Penetration through Exit Stair #3 from access corridor wall that is not fire
sealed.









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Based on observation during the survey walk-through, accompanied by facility staff, not all stair used as exits are constructed in accordance with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by creating a hazard during evacuation of the building under emergency conditions.

Findings include:

A. The distance between guardrails was observed to be in excess of 4" to comply with subpart (3) to 7.2.2.4.6 and 19.2.2.3. This condition was observed in multiple exit stairs. Example locations of Exit stair enclosures at which this condition was observed include:

1. 2:30pm 01/21/2015 Exit Stair # 8 at First floor


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2. 9:16 AM on 01/21/2015: North Pavilion South Exit Stair No. 6.
3. 9:52 AM on 01/21/2015: North Pavilion North Exit Stair No. 5.

Based on observation with the Facility representatives, the surveyor finds that not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 9:55 AM on 01/21/2015, on the Third Floor of South Pavilion, it was observed that signage is not provided at this level inside the stair, identifying which floors are locked against re-entry and where the exit stair discharge is in accordance with 7.2.1.5.2.

B. At 2:30 PM on 01/21/15, on the Second Floor of South Pavilion, The ICU Suite configuration and the arrangement of the southwest exit access corridor for the adjacent Cancer Center, created a dead end corridor of excessive length. This condition does not comply with 19.2.5.10.

C. At 10:20 AM on 01/22/2015, on the first floor of the South Pavilion, it was observed that Stair 1 is not equipped with an interrupter gate which would prevent occupants leaving the building from inadvertently traveling to the basement instead of to the exit discharge. 7.7.3



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During the survey walk-through, accompanied by facility staff, it was observed that exit access is not arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the building.

Findings include:

A. At 11:08 AM on 01/21/2015, on the second floor of the North Pavilion, the pair of cross corridor doors located by the south elevators are provided with exit signage. One leaf is equipped with manual flush bolts, which would entail more than one operation to open.

During the survey walk-through, accompanied by facility staff, it was observed that exit access is not arranged so that exits are readily discernable at all times in accordance with 18.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to choose the proper path of egress.

Findings include:

A. Exit signage was observed to be placed over what appear to be control doors which are locked at night against entry from elevator lobbies into various patient areas. Travel distance within the lobby appears to comply with 18.2.5.10, so these doors are not in a required means of egress from the lobby side. Egress from the patient areas is always available. Locations include:

1. Commencing at 2:24 PM on 01/20/2015, on floors 4 through 7 in the West Pavilion, both the north and south elevator lobbies. On floor 3, the south elevator lobby.

Based on observation during the survey walk-through while accompanied by the Facilities Representative not all designated suites comply with 19.2.5 concerning the remotely located exit access doors. This condition may affect patients, staff and visitors during a fire emergency by increasing the amount of time and travel distance required to reach an exit access corridor.

Findings include:

A. On 1/22/2015 at 1:30pm, First floor Outpatient Lab, the travel distance from the most remote exam room to the means of egress corridor does not comply with 19.2.5.8 for multiple intervening rooms having a travel distance of 50' or less. Surveyor observed two intervening rooms (access aisle and a waiting room) with a travel distance of approximately 70' to an exit access corridor door.

Based on observation during the survey walk-through, not all exit discharge locations are provided with illumination to comply with NFPA-101, Sections 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

A. Exterior egress path was observed that is not provided with lighting, on emergency power, so that the failure of one fixture (bulb) will not leave the area in darkness to comply with 19.2.8.

Location observed:
1st floor non designated stair located in the South/East part of building adjacent to the Physical Therapy suite has no exterior lighting above the discharge door.

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

A. At 8:55 AM on 01/21/2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in South Pavilion -Elevator Lobby, Third Floor by Stairwell #1, which is located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

B. At 9:15 AM on 01/21/2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in South Pavilion - Med/Surge, Third Floor, in Clean Room 3612, which is located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

C. At 9:20 AM on 01/21/2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in South Pavilion - Med/Surge, Third Floor, in Soiled Utility Room 3614, which is located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

D. At 9:45 AM on 01/21/2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in South Pavilion, Third Floor, from POB link entrance to Mother /Baby, which is located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

E. At 8:55 AM on 01/21/2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in South Pavilion, Third Floor, Elevator Lobby, which is located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

F. At 1:30 PM on 01/21/2015 the surveyor observed that the unoccupied fire pump room in the south pavilion housed a fire alarm panel and was not equipped with a smoke detector to meet the requirements of NFPA-72, Section 1-5.6.



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Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

A. At 2:36 PM on January 20, 2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in West Building - Med/Surge, Fifth Floor exit access corridor near Soiled Holding Room W5529, which is located within
3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

B. At 2:38 PM on January 20, 2015, while accompanied by the Maintenance Supervisor and a Maintenance Staff, the Surveyor observed a smoke detector, in West Building - Med/Surge, Fifth Floor, and Room 5521 next to Medication Room W5519, which is located within
3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

Based on observation during the survey walk-through, accompanied by facility staff, the facility failed to provide a fire alarm system with approved components, devices or equipment installed according to NFPA 72. This deficiency would affect all occupants if there was a delay in the fire alarm system ' s response time during a fire.

Findings include:

A. At 9:38 and 9:55 AM, respectively, on 01/21/2015, on the fifth floor of the North Pavilion, smoke detectors were observed to be located within 18 inches of a supply air diffuser. Locations observed are at both the east and west cross corridor doors.

Based on direct observation during the survey walk-through, with the Maintenance Supervisor and staff maintenance, the surveyor find that not all portions of the building fire protection systems and materials are installed and maintained in accordance with NFPA 13 - 1999.

Findings include:

A. By direct observation 1/20/15 at 10:00 AM while in the company of the Director of Engineering / Construction,the surveyor finds the generator room is not provided with a complete sprinkler fire suppression system. NFPA 13, 1999, 1-6.1 & 13, 5-1.

B. The following rooms were observed to lack sprinkler protection:

1. 10:11 AM on 01/22/2015, in the basement of the South Pavilion: Shower Room SL275 in the Nuclear Medicine Department.
2. 10:23 AM on 01/22/2015, on the first floor of the South Pavilion: the IT closet adjacent to the Cancer Center Entry Vestibule.


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C. At 10:45AM, on 01/21/2015, sprinkler head escutcheons were observed to be missing to comply with NFPA 13-1999. Locations include:

1. Fourth Floor - Elevator Lobby.
2. Fourth Floor - Electrical Room S4381.


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Based on observation during the survey walk, while accompanied by facility staff, failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors.
Findings include:

A. By direct observation 1/20/15 at 9:00 AM while in the company of the Director of Engineering / Construction the surveyor find the Generator Room W2664 is not provided with a sprinkler fire suppression system. NFPA 13, 1999, 1-6.1 & 13, 5-1.


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B. 01/20/2015 at 2:30pm 1st floor Stair # 3 a sprinkler head is damaged within this stair which does not comply with NFPA 13, 1999 edition.

Based on observation during the survey walk, while accompanied by facility staff, failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors. The installation does not comply with NFPA 13 1999

Findings include:

A. By direct observation 1/21/15 at 1:30 PM while in the company of the Director of Engineering / Construction the surveyor find the IT / Communications and Electrical closets on 5th Floor are not provided with fire suppression. (NFPA 13, 1999, 1-6.1 & 13, 5-1.)

B. By direct observation 1/21/15 at 1:45 PM while in the company of the Director of Engineering / Construction the surveyor find the IT / Communications and Electrical closets on 4th Floor are not provided with fire suppression. (NFPA 13, 1999, 1-6.1 & 13, 5-1.)

C By direct observation 1/21/15 at 2:00 PM while in the company of the Director of Engineering / Construction the surveyor find the IT / Communications and Electrical closets on 3th Floor are not provided with fire suppression. (NFPA 13, 1999, 1-6.1 & 13, 5-1.)

D. By direct observation 1/21/15 at 2:15 PM while in the company of the Director of Engineering / Construction the surveyor find the Lower Level Morgue room NL784 that the body holding cooler is not provided with sprinkler fire protection. (NFPA 13, 1999, 1-6.1 & 13, 5-1.)

E. By direct observation 1/21/15 at 2:30 PM while in the company of the Director of Engineering / Construction the surveyor find the Electrical Room/Sub Station No. 1 room NL728 is not provided with sprinkler fire protection. (NFPA 13, 1999, 1-6.1 & 13, 5-1.)




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F. 01/22/2015 at 11:30am Lower level elevator alcove for Elevator # 1 was observed which is not provided with sprinkler protection in a building which is otherwise considered fully protected.

Based on direct observation during the survey walk-through, with the Maintenance Supervisor and staff maintenance, the surveyor find that not all portions of the building fire protection systems and materials are installed and maintained in accordance with NFPA 72. This deficiency could delayor prevent notification of a fire event to affect all patients, staff, and visitors.

A. By direct observation 1/20/15 at 10:15 AM while in the company of the Director of Engineering / Construction, the surveyor finds in Fire Pump Room (SL387), the main incoming water supply valve for the fire suppression system is not provided with tamper protection and alarm.

Based on observation during the survey walk through the surveyor accompanied by the Director of Engineering/Construction finds that fire dampers are not installed and maintained to comply with NFPA 90A . Failure to maintain fire dampers will result in failure of fire dampers in a fire emergency which could allow migration of fire and smoke to spread throughout patient areas and to multiple patient floors.


A. 6th Floor Mechanical Penthouse:
By direct observation 1/20/15 at 1:30 PM while in the company of the Director of Engineering / Construction the surveyor find the facility failed to provide a fire damper for the duct penetration from AHU 55 to the duct chase. (NFPA 90A, 1999, 3-3.4)

Based on observation during the survey walk-through, not all portions of the building trash chute system is installed in accordance with NFPA 82 1999.

Findings include;

A. 01.22.2015 at 11:00am Lower level Trash chute discharge room, the room does not maintain a required 2-hour fire resistant enclosure to comply with NFPA 82 3-2.6.1 due to the following:

1. Numerous polyvinyl chloride (PVC) pipes penetrate the floor and the walls of the room which lack the proper through wall/floor U.L. listed design.

2. A PVC pipe penetrates the 2-hour fire rated floor above and is open to the discharge room at the end of the pipe run.

3. The chute discharge room entry door does not close to latch.

4. A through wall ducted vent located above the room's entry door lacks a fire damper.

5. A partial duct penetration through the West wall of the discharge room located behind the chute's door, appears to be capped off with material that does not maintain the rooms 2-hour fire rating.

6. There is a hole through the corridor wall of the room.


B. 01.22.2015 at 11:00am Lower level electrical closet is accessed through the trash discharge room. The walls of the electrical closet (labeled 2-hour) do not maintain a 2-hour separation between the discharge room and the closet due to the following:

1. The closet walls do not continue to the underside of the floor above. The floor deck is a fluted metal deck having gaps between the top of the wall and bottom of the deck.

2. The closet wall contains an exposed wood stud at the corner.

3. The closet entry door does not maintain a 1 1/2 hour opening due to the door hardware and door frame.

4. Duct penetrations through the closet 2-hour walls lack damper installations.



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C. Doors to trash chutes were observed that did not carry a minimum fire resistance rating required by 19.5.4.1 and NFPA 82 1999 3-2.3. Locations observed include:

1. 9:23 AM on 01/21/2015, on the fifth floor of the North Pavilion in the south Housekeeping Room.

2. 10:27 AM on 01/21/2015, on the third floor of the North Pavilion in the south Housekeeping Room.

Based on observations during the survey walk-through, accompanied by facility staff, the facility failed to keep the means of egress free of obstructions and impediments to use in accordance with 7.1.10. This deficiency could affect all patients, staff, and visitors on the cited floors in the event of an emergency requiring egress or relocation.

Findings include:

A. The following exit access corridors were observed to contain idle beds, equipment, trash receptacles, etc. These items partially blocked the required clear width of the corridors:

1. 9:03 AM on 01/22/2015, in the basement of the South Pavilion: the corridor serving Stair 4.
2. 9:35 AM on 01/22/2015, in the basement of the South Pavilion: the corridor serving Stair 2.
3. 11:02 AM on 01/22/2015, on the first floor of the South Pavilion: the corridor serving the Respiratory Equipment Room S1503.

Based on observations during the survey walk-through, accompanied by facility staff, the facility failed to provide a proper storage of oxygen cylinders in accordance with NFPA 99. This deficiency could endanger staff and patients in the event of a gas related fire.

Findings include:

A. At 9:27 AM on 01/22/2015, in the basement of the South Pavilion, the light switch in Med Gas Storage SL306A was observed to be mounted less than 5 feet above the finished floor as required by NFPA 99 1999 4-3.1.1.2 (a)4.

During the survey walk through, accompanied by facility staff, it was observed that the facility failed to provide a medical gas installation that is in compliance with NFPA 99. These deficiencies could endanger patients and staff in the event of a gas system related fire.

Findings include:

A) Medical gas shut-off valves and/or alarm panels do not accurately identify the rooms or zones controlled to comply with NFPA 99, 1999. Surveyor observed this condition throughout the facility. Example location:

1) 1st floor, Cardiac Cath Lab - valve for the procedure room reads Cath Lab M34, paper sign next to valve reads zone valve rooms S1318 and S1320A, signage on the Cath Lab door reads S1318 and Cath Lab # 1, none of these match.

B) Medical gas shut-off valves are located such that there is no separation between the valve and the location of the medical gas outlets served. This condition does not comply with NFPA 99, 1999 Edition 4-3.1.2.3 (d. Location observed:

1) 1st Floor Ultrasound Suite (2,830s.f.)- There is a valve which is open to the outlets served. The prep/recovery bays contain privacy curtains. The shut off valve is located such that there is no wall intervening between the valve and the outlets served. Therefore, staff is not allowed to shut off the flow of gas without being exposed to the fire scene.

2) By direct observation 1/20/15 at 10:30 AM while in the company of the Director of Engineering / Construction, the surveyor find the medical gas zone valves (No. 37) installed for the Emergency Room are not separated from the treatment and exam rooms outlets and inlets they serve. (NFPA 99, 1999, 4- 3.1.2.3 (d)

3) By direct observation 1/20/15 at 11:00 AM while in the company of the Director of Engineering / Construction, the surveyor find the medical gas zone valves (No. 33) installed for the ICU are not separated from the patient rooms outlets and inlets they serve. (NFPA 99, 1999, 4-3.1.2.3 (d)

During the survey walk-through, accompanied by facility staff, it was observed that the generator room lacks a 2 hour fire rated enclosure as required by NFPA 99 1999 3-4.1.1.6(a). This deficiency could affect all patients, staff, and visitors in the event of a fire in the generator room.

Findings include:

A. At 9:20 AM on 01/22/2015, in the basement of the South Pavilion, it was observed that there is an unsealed pipe penetration in the fire rated east wall of the generator room.

This STANDARD is not met as evidenced by:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the
survey walk-through, the provider shall institute the appropriate Interim Life Safety Measures
until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan
of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all
such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

This STANDARD is not met as evidenced by:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute the appropriate Interim Life Safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all
such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

Based on observation during the survey walk, while accompanied by facility staff, failure to install and maintain the emergency eye wash stations could result in injury to staff under emergency use conditions. The installation does not comply with NFPA 99.

A. By direct observation 1/20/15 at 1:15 PM while in the company of the Director of Engineering / Construction the surveyor find the eye wash installed in Soiled Holding W6529 is not provided with a pressure regulating means in compliance with NFPA and ANSI Z358.1.

Based on observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the hospital if the emergency power system does not operate correctly.

Findings include:

A. On Wednesday, January 21, 2015 at approximately 10:20 A.M. the surveyor observed that the transfer switch in the electrical room on the lower level of the north pavilion served by substation #1 was serving a distribution panel that served loads from all branches of emergency power. NFPA-70, Section 517-30 requires that each branch of the essential electrical system be served by one or more transfer switches when the essential electrical system demand exceeds 150KVA.

B. On Wednesday, January 21, 2015 at approximately 10:00 A.M. the surveyor observed that the EM panel on each floor of the north pavilion was serving a mixture of life safety, critical and equipment loads. For example panel EM-60-M1 was serving mostly life safety loads, but was serving a board room heater on circuit 35. These panels were also served from a distribution panel on the lower level that was served from a single transfer switch and served all branches of emergency power.

Based on direct observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect any patient if the transfer switch serving these rooms fails.

Findings include:

A. On Wednesday, January 21, 2015 at approximately 2:00 PM the surveyor observed that the operating rooms were not equipped with normal receptacles to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

B. On Wednesday, January 21, 2015 at approximately 2:20 PM the surveyor observed that the PACU was not equipped with normal receptacles at the headwall of each bed location to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

C. On Wednesday, January 21, 2015 at approximately 1:45 PM the surveyor observed that the cab lighting for the hydraulic elevator serving the cancer center was not served from the life safety panel as required by NFPA-70, Section 517-32, and there was not a disconnect switch for cab lighting and controls within the elevator equipment room as required by NFPA-70, Section 620-22. This could affect any occupant of the building using the elevator during a power outage.

Based on observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

A. On Wednesday, January 21, 2015 at approximately 9:00 A.M. the surveyor observed that the elevator cab lights in the penthouse of the knuckle area of the north pavilion for elevators D, E, and F were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32.

B. On Wednesday, January 21, 2015 at approximately 9:45 A.M. the surveyor observed that the elevator cab lights for elevator H in the north pavilion were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32, and they were not equipped with a disconnect in the elevator equipment room in accordance with NFPA-70, Section 620-53.

Based on observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the elevators did not meet all of the requirements of ANSI/ASME A17.3. This could affect any occupants of the facility using the elevator if proper safety equipment is not installed on each elevator.

Findings include:

A. The north pavilion elevator machine room for elevator H did not have a heat detector within 2' of each sprinkler head tied to a shunt trip as required by NFPA-72, Section 3-9.4, and ASME A17.1, Section 102.2(c)(3).