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Based upon observation during the survey walk-through, not all building components are protected to afford the required fire rating. This deficient practice could affect patients, staff and visitors if failure to provide protection can result in premature failure of the building components during a fire condition.

The finding is:

On 02/06/2019 while in the company of the MS through floor openings were observed containing multiple pipe/conduit runs. The openings did not maintain the posted U.L. design (#CAJ 8056). These barriers do not comply with the requirements of 19.1.2.3 as being constructed of materials which maintain a 2-hour fire rated floor construction.

Locations observed,
1. At 9:30 am Building A Penthouse, South East corner, mechanical chase area.
2. At 1:15 pm Building B Second floor, Telecommunication closet, south side of corridor in the direction of the horizontal exit.

Based on observation, stairways used as exits contained incorrectly identified paths of egress. These deficiencies could affect patients, staff and visitors within the areas of the facility if the occupants cannot identify the available exit discharges.

Findings include:

A. On 02/06/2019 while in the company of the MS exit stairs which served five or more total stories in both Building A and Building B lacked identification to comply with 19.2.1, 7.2.2.5.4. Example locations:

1. At 1:50 pm First floor, Building A, South Stair (Stair A).
2. At 2:00 pm First floor, Building A, North Stair.

Based upon observation during the survey walk-through, not all building components are protected to afford the required fire rating. This deficient practice could affect patients, staff and visitors if failure to provide protection can result in premature failure of the building components during a fire condition.

The finding is:

On 02/06/2019 at 2:10 pm while in the company of the MS a through wall opening was observed within the wall of the indicated horizontal exit. This barrier does not comply with the requirements of 19.1.2.3 as being complete and constructed of materials that conform to a 2-hour fire resistant rating.

Location observed: Second floor, Respiratory therapy office/Stair wall between Building B and C.

Based on observations, means of egress are not maintained with a minimal level of lighting under all conditions. This deficient practice could affect patients, staff and visitors if a failure to maintain means of egress illuminated can prevent occupants from reaching an exit in the event of a fire/smoke emergency.

Findings include:

A. On 02/07/2019 at 9:15 am while in the company of the MS an observation determined that an exterior discharge does not comply with 7.8.2.1. Location observed: Ground floor, Building A exterior discharge from Radiology suite.

B. On 02/06/2019 at 10:00 am while in the company of the MS, it was noted that the Building B exit stair fourth floor and third floor landing contains a light switch which controls illumination at stair landings. This does not comply with 19.2.8, 7.8.2.1.

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 if it prevented occupants from readily identifying the path to an available exit from the building.

Findings include:

A. On 02/06/2019 while in the company of the MS exit signage was observed to be partially obstructed or missing which provides for dead end corridor conditions, and further does not comply with 19.2.5.2, 7.5.1, 7.10.1.2.1 or 7.10.1.5.1. Example locations:

1. At 2:50 pm Ground floor, Building A, corridor looking North from Waiting.
2. At 3:00 pm Ground floor, Building A, corridor looking East toward main Lobby from elevators
3. At 1:45 pm First floor Building B, corridor looking East toward Building C.
4. At 11:15 am Fourth floor, Building A, ICU suite, north hallway with a view to the East.

B. On 02/07/2019 at 11:15 am while in the company of the MS, the direction of exterior egress travel from Building A, South Stair "A", discharge is not readily apparent in order to comply with 7.7.3.2 and 7.10.1.5.1.

Based on observation during the survey walk through the facility failed to maintain compartment separations between floors/areas. This deficient practice could affect patients, staff and visitors if occupants could not safely reach an exit on a floor level during a fire event on a separate level.

The findings are:

A. On 02/07/2019 at 10:10 am while in the company of the MS a multi-story stair shaft appears open to a storage room. The shaft is not enclosed in fire rated construction to comply with 19.3.1.1. Location observed: Ground floor Building A, North exit stair, closet entry in stair vestibule and below stair run. The Facility did not provide a listed design for this installation to comply with 7.2.2.5.31 and 7.2.2.5.3.2.

B. On 02/07/2019 at 10:40 am while in the company of the MS, an exit stair enclosure is not separated from utilities and services which do not serve the stair. This condition does not comply with 7.1.3.2.1 (10).

Location and conditions observed: Basement floor, Building A, North exit Stair;
1. A 4" diameter conduit with an LB hub, runs into and vertically up the stair.
2. A 1" diameter conduit runs into and vertically up the stair.
3. A 1" diameter conduit runs through the stair at the Basement level.
4. A 1" diameter conduit runs through the stair at the Basement level. This conduit is open at one end.

Based upon observation, hazardous areas within a partially sprinklered building are not separated by fire resistant construction. This deficient practice could affect patients, staff and visitors if a failure to separate hazardous areas were to expose occupants to fire conditions before evacuation occured.

The findings are:

A. On 02/06/2019 at 10:35 am while in the company of the SD areas of storage are considered hazardous due to the amount of combustible material within each room. Each room is greater than 50 square feet and is not sprinkler protected. The means of egress door and frame from each room does not comply with 19.3.2.1.2 and 19.3.2.1.3 for a fire resistant door and frame installation.

Example locations observed:
1. Building B, fourth floor, Sterile Processing,
2. Building B, fourth floor, Clean room,
3. Building B, fourth floor, Storage room.

B. On 02/06/2019 at 10:40 am while in the company of the SD areas of storage are considered hazardous due to the amount of combustible material within each room. Each room is greater than 50 square feet and is sprinkler protected. A door to a hazardous room was observed which does not comply with 19.3.2.1 and 8.4 for separation requirments.

Location observed:
1. Building B, fourth floor "Sterile room" door does not latch.
2. Building B, fourth floor "Sterile room" door contains an amount of glazing which exceeds the square inch requirements of NFPA 80 2010, 4.4.

Based on an observation, the facility failed to properly install all required initiating devices to provide a functioning fire alarm system. This deficient practice could affect patients, staff and visitors if smoke was not detected and the fire alarm system did not operate due to the placement of a smoke detector.

Findings include:

On 02/07/2019 while accompanied by the MS, locations of fire alarm control units in unoccupied areas do not comply with 9.6, and NFPA 72 2010 Edition, Section 10.15. Locations observed:

1. At 12:45 pm, Basement floor: location of Main Fire Alarm Control Panel.
2. At 12:40 pm, First floor: MRI Equipment room, Fire Alarm NAC Panel.

Based on observation, the facility failed to install and maintain automatic sprinkler protection in accordance with the code requirements. This deficient practice could affect patients, staff and visitors if activation of a sprinkler head were delayed during a fire emergency.

The finding is:

On 02/06/2019 while accompanied by the MS, sprinkler head escutcheons were missing or hanging loose from the ceilings. These conditions do not comply with NFPA 25-2011 5.2.1.1.2(3).
Example locations include:

1. At 2:30 pm Building B, Fourth floor Storage room adjacent to the horizontal exit, south side of corridor.
2. At 10:30 am Building B, Fourth floor Storage room adjacent to the horizontal exit, south side of corridor.
3. At 10:40 am Building B, Second floor Storage room adjacent to the horizontal exit, south side of corridor.
4. At 2:45 pm Building B Second floor, Telecommunications closet, south side of corridor.
5. At 3:00 pm Building B First floor Gift Shop.

Based upon document review, the facility failed to provide standard inspections for the vertical conveying systems. This deficient practice could affect patients, staff and visitors if emergency personnel were unable to us an elevator during a fire/smoke emergency.

The finding is:

On 02/07/2019 at 11:35 am while accompanied by the MS,document review could not be provide for the monthly testing of the elevators' fire fighters service and recall functions to comply with ASME A17.1. (NFPA 101, 2012, 9.4.6.2).

Based upon review of record documentation of door inspections, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. This deficient practice could affect, patients, staff and visitors if a failure to maintain doors can compromise adjacent spaces during a fire condition.

The finding is:

On 02/07/2019 at 11:30 am, while in the company of the MS and VPAS, documentation for fire rated doors was reviewed. Documentation provided was the 2017 inspection report and the 2018 "Relabeling Report" which does not comply with 7.2.1.15.3. The following information was not available:

1. The "Relabeling Report" indicated a list of doors requiring maintenance
i. There is no resolution of corrections on some doors which does not comply with 7.2.1.15.8.
ii. Some doors are listed as "unable to access", unable to label as required to comply with 7.2.1.15.4.
iii. Some doors reference the AHJ's responsibility to determine their fire rating which does not comply with 7.2.1.15.2.
2. There is no indication a complete fire door inspection was conducted for 2018 to comply with 7.2.1.15.3.
3. Documents did not indicate the actual repair or maintenance provided for each door's condition. The documents do not comply with NFPA 80 2010, 5.2.1.

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

The finding is:

On 02/07/2019 at 10:25 am while accompanied by the VPAS., observation determined that critical care patient beds lack electrical receptacles served by normal power as required by NFPA 70 2011 517-19(A).
The location observed: Building B, Third floor C-Section procedure room

Based upon observation, oxygen storage rooms are not maintained in accordance with Code requirements. This deficient practice could affect patients, staff and visitors if a failure to maintain oxygen storage in accordance with Code requirements were to result in occupant exposure to hazardous conditions that contribute to a fire.

The finding is:

On 02/07/2019 at 1:40 am while in the company of the MS, it was observed that an med-gas storage room contains numerous unsupported cylinders which does not comply with NFPA 99-2012, 5.1.3.3.2 (7).
Location observed: Ground floor, Building A, Gas equipment storage room exterior side of ED.