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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, the construction type of the building does not comply with NFPA 101 - 2000, 19.1.6.2. This deficiency could affect all patients in the facility, and any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:

A. A beam in the chase space behind the Electrical closet at the west side of the Lab was observed to have the fireproofing removed.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, not all rooms are confirmed to have interior flame spread ratings in accordance with 19.3.3.1 and 10.2.3.1. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by allowing smoke and fire to develop.

Findings include:

A. The Chapel was observed to have wood paneling walls that could not be confirmed to meet the minimum Class C flame spread/smoke development ratings.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12./11, 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 facility, as well as any staff and visitors present, because the lack of smoke detectors could result in delayed response to fire/smoke conditions which compromise the facility's use of the exit access corridors.

Findings include:

A. The 3rd floor 1927/57 building was observed to have an alcove open to the corridor utilized for storing 3 folding beds and a cart. The space was provided with sprinkler protection but not smoke detection to comply with 19.3.6.1 Exception No.1.

B. The 1st floor 1980 building Main Lobby Waiting areas, Registration area and Lab Draw space are open to the corridor. These spaces have varying ceiling heights and configurations. The smoke detection provided is not adequate to protect each space individually to comply with 19.3.6.1 Exceptions No.1 and 2.

C. The 1st floor 1975 building Lab Waitng area is open to the corridor and not provided with smoke detection to comply with 19.3.6.1 Exception No.2.

D. The south corridor door of the Surgery suite is not positve latching to comply with 19.3.6.3.2.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:

A. The 1927 building old dumbwaiter shaft has been closed with rated wall construction with access doors. The access doors were observed to not be self-closing due to the removal of the springs. Locations observed include:

1. The 3rd floor.

2. The 2nd floor.

B. Miscellaneous pipe penetrations were observed not to be sealed in accordance with fire/smoke rated tested design assemblies. Locations observed include but are not necessarily limited to the following:

1. The 2nd floor 1927 building Storage room adjacent Elevator #5 was observed to have exposed PVC drain piping in the toilet room through the floor. The extent of this piping was not confirmed as to the number of floors penetrated. The manner in which protection was provided was not readily visible.

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, not all hazardous areas are separated from the remainder of the building in accordance with 38.3.2.1 and 8.4.1. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access.

Findings include:

A. Storage rooms containing materials having a greater degree of hazard than that normal to the general occupancy of the building were observed without self-closing doors to comply with 8.4.1.2 and 8.2.4.3.5 at the following locations:

1. At the Sleep Lab equipment storage room adjacent the door from the Lobby area.

2. At the File Storage room adjacent the Reception area.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients of the smoke compartment, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:

A. The 4th floor 1957 building contained former patient rooms which were utilized for storage of beds, furnishings and equipment which was vacated from other rooms that are being utilized by the Cancer Care Center. These rooms are considered as new hazardous areas due to their recent change of use. The rooms were not enclosed with 1-hour rated construction including self-closing 3/4-hour rated doors to comply with 18.3.2.1. Rooms included but may not be limited to 4105, 4113, 4115, 4117 & 4119.

B. The 3rd floor 1980 building Labor/Delivery Decontamination room contaning greater than 32 gal. of soiled linen/waste materials was observed to have a corridor door which did not close to a latched condition to comply with 8.4.1.2, 8.2.4 and 19.3.6.3.2.

C. The 1st floor 1927 building Perioperative Storage Room door was observed to have a corridor door which did not close to a latched condition to comply with 8.4.1.2, 8.2.4 and 19.3.6.3.2..

D. The Ground floor Emergency Room Soiled Utility room door was observed to have a door which did not close to a latched condition to comply with 8.4.1.2, 8.2.4 and 19.3.6.3.2.
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Based on random observation during the survey walk-through on 10/12/11, Laboratories employing quantities of flammable, combustible materials are not protected in accordance with 19.3.2.1. These deficiencies could affect all patients on the 1st floor of the facility, as well as any staff and visitors present, by exposing the facility to fire and smoke in the event of ignition.

Findings include:

A. The Lab suite corridor door from the Lobby was not self-closing to a latched condition in compliance with 19.3.2.1.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, not all exit or exit access doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, required to utilize the doors by preventing those occupants from reaching an exit from the building.

Findings include:

A. Doors equipped with magnetic locking devices do not comply with all requirements of 19.2.2.2.4 and 7.2.1.6. Conditions and locations observed:

1. The 4th floor cross corridor doors used to secure the Peds area do not have a delayed egress function on the door leaf entering the area at the north corridor which is marked with exit signage. Similar conditions may exist at the south corridor entrance.

2. The 3rd floor Labor & Delivery northwest entry doors equipped with delayed egress hardware did not release under fire alarm activation to comply with 7.2.1.6.1(c).

3. The 2nd floor single swing door between the 1927 and 1957 buildings is equipped with a lock to secure the Ambulatory Care area after hours. Egress is required in both directions to prevent a dead end condition on both sides of the door.

4. The Ground floor cross corridor doors between the ER Lobby area and the Radiology corridors are locked after hours. The doors did not have an operational delayed egress function at the time of the survey to comply with 7.2.1.6.1(c).

5. The doors equipped with delayed egress function are not provided with signage in accordance with 7.2.1.6.1(d) to indicate that the doors will release within a specified time delay. A letter from IDPH granting approval to delete the signage was not otherwise available.

B. Doors are equipped with hardware which requires more than a single releasing operation to operate the door in non-compliance with 7.2.1.5.4. Conditions and locations include but are not necessarily limited to the following:

1. The 4th floor 1980 building House Supervisor's office door is equipped with both a latchset and a keyed dead bolt lock. The dead bolt lock is not operable from inside the room.

2. The 4th floor 1927 building Pharmacy has two doors equipped with both a lockset and a dead bolt lock.

3. The 4th floor 1927 building Pharmacy Conference room door is equipped with both a lock and lockset.

4. The 4th floor 1957 building old psych patient rooms 4109 and 4110 toilet rooms are equipped with dead bolt locks without provisions for unlocking from inside the room.

5. The 3rd floor 1980 building 3W Kitchen/Nourishment room door is equipped with two leversets. One is operational, the other is not. The two leversets present a condition where the operation of the door releasing device is not readily obvious. The original leverset at standard height is the inoperable leverset.

6. The 3rd floor 1980 building Breakroom door is equipped with both a dead bolt and latchset.

7. The 3rd floor 1980 building 3W Secretary room door is equipped with both a dead bolt and latchset.

8. The 2nd floor 1927 building Female Locker room door near Elevator #5 has both a dead bolt and a latchset.

9. The 1st floor Lab suite northwest double egress door is designated as the exit path for the corridor outside the Lab suite. These doors are equipped with slide bolts on both doors. The door leaf providing exiting into the Lab suite is non-compliant with 7.5.1.2 (See also K47). The door leaf providing exiting for the Lab suite is non-compliant with 7.2.1.5.4 because the slide lock is a second operation and is located more than 48" above the floor. The corridor/waiting area outside the Lab suite has only a single compliant exit path when the exit path through the suite is removed.

10. The 1st floor Surgery east exterior exit sliding doors are equipped with a keyed dead latch which prevents the break-and-swing function when the dead latch is engaged.

11. The Ground floor Kitchen west door to the loading area is equipped with slide bolt locks. The slide locks are not in compliance with 7.2.1.5.4.

12. The Ground floor 1980 building Cath Lab doors are equipped with both dead bolt locks and latchsets.

13. The Ground floor 1980 building X-ray room doors are equipped with both dead bolt locks and latchsets.

C. The 2nd floor 1927 building west stair #4 contains a chase construction to separate the Data Center extinguishing system from the stair. However, the required 2-hour separation is not maintained at the perimeter of the access door as evidenced by the observation of unprotected wall stud framing.

D. The 2nd floor 1980 building Mechanical room southwest stair door did not self-close to a latched condition.

E. The 1st floor 1957 building corridor leading to the north stair is painted with a wall mural. The exit stair door is incorporated into the mural. The stair door is not readily recognizable as the required exit door to comply with 7.1.10.2.1 as the visibility and identification of the door is obscured by the graphic mural. Signage to clearly identify the door is not otherwise provided on the door or immediately adjacent the door.

F. The 1st floor Lobby level southwest stair vestibule contains umbrella wrappers and a Dr. message center within the stair enclosure in noncompliance with 7.1.3.2.3.

G. The Basement level 1980 building corridor functions as the discharge path for the center stair. It does not appear that this stair is required to discharge through an exit passageway. The common path of travel distance from the staff breakroom adjacent the elevators to the only defined exit exceeds the 100' allowed in a fully sprinkler protected occupancy. Therefore, the corridor appears to be required to comply as an exit passageway. This corridor does not comply as an exit passageway due to non-compliance with 9.4.7 because the elevators open directly onto this corridor. It was also not confirmed that prohibited utilities and systems did not exist above the ceiling of the corridor to allow it to comply as an exit passageway. The west end was observed to have a medical gas zone valve in the corridor wall.

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 38.2.1 and Chapter 7. These deficiencies could affect all out-patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Two main entry doors were observed to be provided with magnetic locking devices which are engaged during night operation of the Sleep Lab. The magnetic locking devices were not installed in full compliance with 38.2.2.2.1 and 7.2.1.6.2 Access Controlled Egress.

1. The installation lacked the sensor required under 7.2.1.6.2(a).

2. It was not confirmed that both doors were equipped with the manual release within 5' of the door as required under 7.2.1.6.2(c).

3. It was not confirmed that the magnetic locking devices were installed to release under fire alarm or sprinkler activation as required under 7.2.1.6.2(d) & (e).

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all occupants of the fire compartments on either side of the fire barrier because the deficiencies could permit fire and smoke to pass between fire compartments.

Findings include:

A. The 3rd floor fire barrier doors between the 1927 and 1957 building areas near the Environmental Services Office did not close to a latched condition.

B. Fire barrier doors did not close to a latched condition when opened after initial closing. It was observed that a light pressure on the panic device could open the doors but not reset to allow the doors to latch upon closing. Locations observed to exhibit this condition included but are not necessarily limited to:

1. The 3rd floor fire barrier doors north of the 1980 building three-elevator lobby.

2. The 1st floor fire barrier doors just east of the elevators in the 1957 building.

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, not all exit discharge locations are provided with illumination to comply with 38.2.8, 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.

Findings include:

A. The exit discharge lighting provided at the east exit was not provided in accordance with 7.8.1.4. The fixture provided was of the single HID lamp type. Surveyor notes that lighting on an emergency power supply is not required per the requirements of 38.2.9.1.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, not all exit discharge locations are provided with illumination to comply with 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.

Findings include:

A. Exit discharge lighting provided was not provided in accordance with 7.8.1.4. The fixtures provided were of the single HID lamp type, a combination of HID and fluorescent or HID and incandescent. Two fixtures or two lamps of the instant-on type were not provided at all locations. It was not confirmed that all discharge lighting was connected to the emergency power system. Locations observed include but are not necessarily limited to the following:

1. The 1980 building southwest stair has a single incandescent soffit fixture. Other exterior pole lighting is of HID type.

2. The 1975 building Stair #6 discharge has a single HID wall mount fixture.

3. The 1966 building exit from the Kitchen has two original incandescent fixtures plus a newer HID fixture. It could not be determined if the original incandescent fixtures were operational.

4. The 1966 building north exit from Surgery is a covered exterior stair provided with one fluorescent fixture and one HID fixture.

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, exit signs did not identify a continuous path of egress in all cases in accordance with 38.2.10 and 7.10. These deficiencies could affect all patients in the Sleep Lab, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.4. The main corridor in the Sleep Lab does not have visible exit signage when observed from the middle sleeping room. The signage provided is located at the wall of the doors where not placed to be visible in compliance with 7.10.1.7.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, exit signs did not identify a continuous path of egress in all cases in accordance with 19.2.10 and 7.10. These deficiencies could affect all patients as well as any staff and visitors present required to utilize the exit path, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.4. Areas lacking exit signage in accordance with requirements include the following:

1. The 4th floor 1927 building corridor serving the Pharmacy was observed to have the full visibility of the exit sign to the east obstructed by a door frame.

2. The 4th floor 1957 building exit sign at the north side of the smoke barrier was not illuminated.

3. The 3rd floor 1980 building center corridor was observed to have the the visibility of the exit sign to the north obstructed by other signage.

4. The 2nd floor 1980 building Mechanical room is provided with three exits. However, due to low height ductwork and equipment arrangement, clear pathways to the exits are not obvious to occupants or identified.

5. The 2nd floor 1957 building Endoscopy area double egress cross corridor doors have the exit sign on the north side of the doors located over the door swinging against egress travel rather than the door intended for egress.

6. The 1st floor 1927 building Library lacks exit signage at each side of the door between the office area and the stack area to identify the second required exit path from the suite.

7. The 1st floor corridor northwest of the Lab directs the corridor exit path through the Lab suite in non-compliance with 7.5.1.2.

8. The 1st floor 3-hour door near Elevator #5 is not marked as a required exit path. A dead end corridor condition exists.

9. The Ground floor 1980 building west corridor serving Nuclear Medicine and EEG was not provided with exit signage at the north end to identify the required second path.

10. The Ground floor corridor south of the Kitchen serving Conference room #4 does not have exit signage to identify the path when moving east.

11. The exit sign at the 1957 building elevator machine room stair door is not illuminated.

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Based on random observation during the survey walk through, not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999).

Findings include:

1. No fire alarm notification devices were installed on the 4th floor Elevator Lobby corridor between the cross corridor fire and smoke barrier doors.

2. Audibility of the fire alarm system notification devices in the Dining room/confernce room #2/#3 was difficult to hear.


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3. No audible or visual alarms could be seen or heard in the east side lobby on the first and second floors for elevators one, two and three as required by NFPA-101, Section 9.6.3.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 or on 10/12/11, not all portions of the facility's wet sprinkler system are installed in accordance with NFPA 13 1999. These deficiencies could reduce the prompt activation or the effectiveness of the sprinkler system in the event of a fire condition. The buildings are to be considered fully sprinkler protected.

Findings include:

A. The 4th floor 1980 building Patient Transport room small closet containing the nurse call terminal is not provided with sprinkler protection to comply with NFPA 13-1999, 5-1.1(1).

B. The 4th floor 1927 building Pharmacy area contains rolling shelving units where the backs of the shelving units extend within 18" of the sprinkler head to form an obstrcution to the sprinkler spray pattern in non-compliance with 5-8.5.2.3.

C. The 1st floor Lobby Gift Shop is provided with a slat-board ceiling which could not be confirmed to be resistant to the passage of heat and smoke to effect activation of the sprinkler and smoke detection devices.

D. The 1st floor small Lab Equipment room located outside the Lab suite is not provided with a ceiling. The sidewall sprinkler head is located greater than 4' from the deck above in non-compliance with 5-9.4.1.1.

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E. Based on direct observation 10/12/11, the facility failed to provide automatic sprinkler protection for the following areas. These deficiencies compromise the safety of all occupants and does not allow for fire suppression and alarm to the facility:

1. The basement elevator machine room for Elevator No. 5 (NFPA 13, 1999, 5-13.6)

2. The morgue and body holding cooler (NFPA 13, 1999, 5-1.1)

3. The lowest level of Stair No. 8 (NFPA 13, 1999, 5-13.3.2)

4. 1980 Building patient sleeping room wardrobes (NFPA 13, 1999, 5-1.1)

5. Chapel closet with open ceiling to the unprotected space above (NFPA 13, 1999, 5-1.1)

6. The receiving and loading dock (NFPA 13, 1999, 5-13.8.2)

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Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

F. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7.

G. The fire pump room does not have a battery operated emergency light as required by NFPA 20-2-7.4.

H. The transfer switch for the fire pump is not located at the pump location as required by NFPA 20-6-6.4.

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By direct observation the facility failed to provide:

Identification of service openings for installed fire dampers. (NFPA 90A, 1999, 2-3.4.2)


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By direct observation 10/12/11 and document review 10/11/11, the surveyor finds the facility failed to provide complete fire suppression system inspections for three of three kitchen hood systems. The outside service company's 6 months inspections are documented however monthly inspection by the facility is not being completed and recorded. Impairment of these systems can affect the safety of patients, staff and visitors by delaying alarm and fire extinguishment. (NFPA 17, 1998, 9.2 (dry chemical systems) & 17A, 1998, 5.2 (wet chemical systems)

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. Medical gas tanks were observed being stored in the Sleep Lab room which provides access to the attic that are less than 5'-0" from combustibles not in compliance with NFPA 99 1999 8-3.1.11.2(c)(2). This deficiency could affect all occupants of the facility because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials.

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. Medical gas tanks were observed being stored with combustibles within 5'-0" not in compliance with NFPA 99 1999 8-3.1.11.2(c)(2). This deficiency could affect all occupants of the smoke compartment they are located in because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials. Locations observed include but are not necessarily limited to the following:

1. At the 4th floor 1980 building area Patient Transport storage room.

2. At the 1st floor Lab Equipment room within the Lab suite along the west corridor/aisle.

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A. Based on direct observation 10/12/11, the facility failed to install the medical air compressor intake per NFPA 99, 1999, 4-3.1.1.9. (b). These deficiencies allow for possible contamination of the breathable medical air system and putting patients at risk needing respiratory assistance:

1. The intake is not installed above the roof

2. The intake is constructed using PVC pipe as prohibited by 4-3.2.2.2 (a)


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Based on random observationduring the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.

Findings include:

1. The 250 KW emergency generator did not have a remote annunciator to meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

2. The 250 KW and the 900 KW generators were not equipped with remote emergency shut-down switches to comply with NFPA-110, Section 3-5.5.6.

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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute 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.

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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1.The emergency panels in older north part of the building are not separated by branch as required by NFPA 70, Section 517-30 through 35.

2. The newer south end of the building had life safety, critical and equipment transfer switches, but the critical and life safety loads were mixed in most panels such as panel EMB in the lab area. This does not meet the requirements of NFPA70, Section 517-30 through 35.

3. The fire alarm circuit breakers in the Life Safety Panels were not marked red and have a locking device on the breakers to comply with NFPA-72, Section 1-5.2.5.

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, not all portions of the facility's electrical distribution system are in accordance with NFPA 70 1999.

Findings include:

A. The RPI and HP electrical panels located in the sprinkler system riser room were observed not to have all circuit breakers identified as to their use in accordance with NFPA 70-1999, 384-13. This deficiency could prevent proper identification of a circuit supplying power to an area required to be discontinued in the event of an emergency.

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Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999). Improper grounding could create a shock hazard for all occupants of the building.

Findings include:

1. Staff was not able to locate where the med gas piping was bonded as required by NFPA-70, Section 250.104(c).

2. Duplex receptacles served by emergency power in the C-Section room, the ICU rooms and several other critical care areas are not properly labeled in accordance with NFPA-70, Section 517-19(a).

3. The main water service entrance in the fire pump room was not grounded in accordance with NFPA-70, Section 250-50.

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Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

1. The surveyor observed that the elevator machine rooms were equipped with sprinklers, but there was not a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3. No shunt trip devices were installed on elevator disconnects.

2. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation as required by NFPA-70, Section 620-53.

3. The three elevator doors that open into the equipment room on the third floor were not equipped with a smoke detector tied to the elevator recall system as required by ASME A17.1-211.3b.

4. The surveyor did not observe and staff was unable to verify that the elevators were equipped with fire fighter's service as required by NFPA 101, Section 9.4.3.2, and ANSI A17.3, Rule 211.3.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, the construction type of the building does not comply with NFPA 101 - 2000, 19.1.6.2. This deficiency could affect all patients in the facility, and any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:

A. A beam in the chase space behind the Electrical closet at the west side of the Lab was observed to have the fireproofing removed.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, not all rooms are confirmed to have interior flame spread ratings in accordance with 19.3.3.1 and 10.2.3.1. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by allowing smoke and fire to develop.

Findings include:

A. The Chapel was observed to have wood paneling walls that could not be confirmed to meet the minimum Class C flame spread/smoke development ratings.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12./11, 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 facility, as well as any staff and visitors present, because the lack of smoke detectors could result in delayed response to fire/smoke conditions which compromise the facility's use of the exit access corridors.

Findings include:

A. The 3rd floor 1927/57 building was observed to have an alcove open to the corridor utilized for storing 3 folding beds and a cart. The space was provided with sprinkler protection but not smoke detection to comply with 19.3.6.1 Exception No.1.

B. The 1st floor 1980 building Main Lobby Waiting areas, Registration area and Lab Draw space are open to the corridor. These spaces have varying ceiling heights and configurations. The smoke detection provided is not adequate to protect each space individually to comply with 19.3.6.1 Exceptions No.1 and 2.

C. The 1st floor 1975 building Lab Waitng area is open to the corridor and not provided with smoke detection to comply with 19.3.6.1 Exception No.2.

D. The south corridor door of the Surgery suite is not positve latching to comply with 19.3.6.3.2.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:

A. The 1927 building old dumbwaiter shaft has been closed with rated wall construction with access doors. The access doors were observed to not be self-closing due to the removal of the springs. Locations observed include:

1. The 3rd floor.

2. The 2nd floor.

B. Miscellaneous pipe penetrations were observed not to be sealed in accordance with fire/smoke rated tested design assemblies. Locations observed include but are not necessarily limited to the following:

1. The 2nd floor 1927 building Storage room adjacent Elevator #5 was observed to have exposed PVC drain piping in the toilet room through the floor. The extent of this piping was not confirmed as to the number of floors penetrated. The manner in which protection was provided was not readily visible.

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, not all hazardous areas are separated from the remainder of the building in accordance with 38.3.2.1 and 8.4.1. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access.

Findings include:

A. Storage rooms containing materials having a greater degree of hazard than that normal to the general occupancy of the building were observed without self-closing doors to comply with 8.4.1.2 and 8.2.4.3.5 at the following locations:

1. At the Sleep Lab equipment storage room adjacent the door from the Lobby area.

2. At the File Storage room adjacent the Reception area.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients of the smoke compartment, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:

A. The 4th floor 1957 building contained former patient rooms which were utilized for storage of beds, furnishings and equipment which was vacated from other rooms that are being utilized by the Cancer Care Center. These rooms are considered as new hazardous areas due to their recent change of use. The rooms were not enclosed with 1-hour rated construction including self-closing 3/4-hour rated doors to comply with 18.3.2.1. Rooms included but may not be limited to 4105, 4113, 4115, 4117 & 4119.

B. The 3rd floor 1980 building Labor/Delivery Decontamination room contaning greater than 32 gal. of soiled linen/waste materials was observed to have a corridor door which did not close to a latched condition to comply with 8.4.1.2, 8.2.4 and 19.3.6.3.2.

C. The 1st floor 1927 building Perioperative Storage Room door was observed to have a corridor door which did not close to a latched condition to comply with 8.4.1.2, 8.2.4 and 19.3.6.3.2..

D. The Ground floor Emergency Room Soiled Utility room door was observed to have a door which did not close to a latched condition to comply with 8.4.1.2, 8.2.4 and 19.3.6.3.2.
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Based on random observation during the survey walk-through on 10/12/11, Laboratories employing quantities of flammable, combustible materials are not protected in accordance with 19.3.2.1. These deficiencies could affect all patients on the 1st floor of the facility, as well as any staff and visitors present, by exposing the facility to fire and smoke in the event of ignition.

Findings include:

A. The Lab suite corridor door from the Lobby was not self-closing to a latched condition in compliance with 19.3.2.1.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, not all exit or exit access doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, required to utilize the doors by preventing those occupants from reaching an exit from the building.

Findings include:

A. Doors equipped with magnetic locking devices do not comply with all requirements of 19.2.2.2.4 and 7.2.1.6. Conditions and locations observed:

1. The 4th floor cross corridor doors used to secure the Peds area do not have a delayed egress function on the door leaf entering the area at the north corridor which is marked with exit signage. Similar conditions may exist at the south corridor entrance.

2. The 3rd floor Labor & Delivery northwest entry doors equipped with delayed egress hardware did not release under fire alarm activation to comply with 7.2.1.6.1(c).

3. The 2nd floor single swing door between the 1927 and 1957 buildings is equipped with a lock to secure the Ambulatory Care area after hours. Egress is required in both directions to prevent a dead end condition on both sides of the door.

4. The Ground floor cross corridor doors between the ER Lobby area and the Radiology corridors are locked after hours. The doors did not have an operational delayed egress function at the time of the survey to comply with 7.2.1.6.1(c).

5. The doors equipped with delayed egress function are not provided with signage in accordance with 7.2.1.6.1(d) to indicate that the doors will release within a specified time delay. A letter from IDPH granting approval to delete the signage was not otherwise available.

B. Doors are equipped with hardware which requires more than a single releasing operation to operate the door in non-compliance with 7.2.1.5.4. Conditions and locations include but are not necessarily limited to the following:

1. The 4th floor 1980 building House Supervisor's office door is equipped with both a latchset and a keyed dead bolt lock. The dead bolt lock is not operable from inside the room.

2. The 4th floor 1927 building Pharmacy has two doors equipped with both a lockset and a dead bolt lock.

3. The 4th floor 1927 building Pharmacy Conference room door is equipped with both a lock and lockset.

4. The 4th floor 1957 building old psych patient rooms 4109 and 4110 toilet rooms are equipped with dead bolt locks without provisions for unlocking from inside the room.

5. The 3rd floor 1980 building 3W Kitchen/Nourishment room door is equipped with two leversets. One is operational, the other is not. The two leversets present a condition where the operation of the door releasing device is not readily obvious. The original leverset at standard height is the inoperable leverset.

6. The 3rd floor 1980 building Breakroom door is equipped with both a dead bolt and latchset.

7. The 3rd floor 1980 building 3W Secretary room door is equipped with both a dead bolt and latchset.

8. The 2nd floor 1927 building Female Locker room door near Elevator #5 has both a dead bolt and a latchset.

9. The 1st floor Lab suite northwest double egress door is designated as the exit path for the corridor outside the Lab suite. These doors are equipped with slide bolts on both doors. The door leaf providing exiting into the Lab suite is non-compliant with 7.5.1.2 (See also K47). The door leaf providing exiting for the Lab suite is non-compliant with 7.2.1.5.4 because the slide lock is a second operation and is located more than 48" above the floor. The corridor/waiting area outside the Lab suite has only a single compliant exit path when the exit path through the suite is removed.

10. The 1st floor Surgery east exterior exit sliding doors are equipped with a keyed dead latch which prevents the break-and-swing function when the dead latch is engaged.

11. The Ground floor Kitchen west door to the loading area is equipped with slide bolt locks. The slide locks are not in compliance with 7.2.1.5.4.

12. The Ground floor 1980 building Cath Lab doors are equipped with both dead bolt locks and latchsets.

13. The Ground floor 1980 building X-ray room doors are equipped with both dead bolt locks and latchsets.

C. The 2nd floor 1927 building west stair #4 contains a chase construction to separate the Data Center extinguishing system from the stair. However, the required 2-hour separation is not maintained at the perimeter of the access door as evidenced by the observation of unprotected wall stud framing.

D. The 2nd floor 1980 building Mechanical room southwest stair door did not self-close to a latched condition.

E. The 1st floor 1957 building corridor leading to the north stair is painted with a wall mural. The exit stair door is incorporated into the mural. The stair door is not readily recognizable as the required exit door to comply with 7.1.10.2.1 as the visibility and identification of the door is obscured by the graphic mural. Signage to clearly identify the door is not otherwise provided on the door or immediately adjacent the door.

F. The 1st floor Lobby level southwest stair vestibule contains umbrella wrappers and a Dr. message center within the stair enclosure in noncompliance with 7.1.3.2.3.

G. The Basement level 1980 building corridor functions as the discharge path for the center stair. It does not appear that this stair is required to discharge through an exit passageway. The common path of travel distance from the staff breakroom adjacent the elevators to the only defined exit exceeds the 100' allowed in a fully sprinkler protected occupancy. Therefore, the corridor appears to be required to comply as an exit passageway. This corridor does not comply as an exit passageway due to non-compliance with 9.4.7 because the elevators open directly onto this corridor. It was also not confirmed that prohibited utilities and systems did not exist above the ceiling of the corridor to allow it to comply as an exit passageway. The west end was observed to have a medical gas zone valve in the corridor wall.

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 38.2.1 and Chapter 7. These deficiencies could affect all out-patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Two main entry doors were observed to be provided with magnetic locking devices which are engaged during night operation of the Sleep Lab. The magnetic locking devices were not installed in full compliance with 38.2.2.2.1 and 7.2.1.6.2 Access Controlled Egress.

1. The installation lacked the sensor required under 7.2.1.6.2(a).

2. It was not confirmed that both doors were equipped with the manual release within 5' of the door as required under 7.2.1.6.2(c).

3. It was not confirmed that the magnetic locking devices were installed to release under fire alarm or sprinkler activation as required under 7.2.1.6.2(d) & (e).

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all occupants of the fire compartments on either side of the fire barrier because the deficiencies could permit fire and smoke to pass between fire compartments.

Findings include:

A. The 3rd floor fire barrier doors between the 1927 and 1957 building areas near the Environmental Services Office did not close to a latched condition.

B. Fire barrier doors did not close to a latched condition when opened after initial closing. It was observed that a light pressure on the panic device could open the doors but not reset to allow the doors to latch upon closing. Locations observed to exhibit this condition included but are not necessarily limited to:

1. The 3rd floor fire barrier doors north of the 1980 building three-elevator lobby.

2. The 1st floor fire barrier doors just east of the elevators in the 1957 building.

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, not all exit discharge locations are provided with illumination to comply with 38.2.8, 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.

Findings include:

A. The exit discharge lighting provided at the east exit was not provided in accordance with 7.8.1.4. The fixture provided was of the single HID lamp type. Surveyor notes that lighting on an emergency power supply is not required per the requirements of 38.2.9.1.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, not all exit discharge locations are provided with illumination to comply with 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.

Findings include:

A. Exit discharge lighting provided was not provided in accordance with 7.8.1.4. The fixtures provided were of the single HID lamp type, a combination of HID and fluorescent or HID and incandescent. Two fixtures or two lamps of the instant-on type were not provided at all locations. It was not confirmed that all discharge lighting was connected to the emergency power system. Locations observed include but are not necessarily limited to the following:

1. The 1980 building southwest stair has a single incandescent soffit fixture. Other exterior pole lighting is of HID type.

2. The 1975 building Stair #6 discharge has a single HID wall mount fixture.

3. The 1966 building exit from the Kitchen has two original incandescent fixtures plus a newer HID fixture. It could not be determined if the original incandescent fixtures were operational.

4. The 1966 building north exit from Surgery is a covered exterior stair provided with one fluorescent fixture and one HID fixture.

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, exit signs did not identify a continuous path of egress in all cases in accordance with 38.2.10 and 7.10. These deficiencies could affect all patients in the Sleep Lab, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.4. The main corridor in the Sleep Lab does not have visible exit signage when observed from the middle sleeping room. The signage provided is located at the wall of the doors where not placed to be visible in compliance with 7.10.1.7.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 and on 10/12/11, exit signs did not identify a continuous path of egress in all cases in accordance with 19.2.10 and 7.10. These deficiencies could affect all patients as well as any staff and visitors present required to utilize the exit path, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Egress paths were observed that are not identified by exit signs as required by 7.10.1.4. Areas lacking exit signage in accordance with requirements include the following:

1. The 4th floor 1927 building corridor serving the Pharmacy was observed to have the full visibility of the exit sign to the east obstructed by a door frame.

2. The 4th floor 1957 building exit sign at the north side of the smoke barrier was not illuminated.

3. The 3rd floor 1980 building center corridor was observed to have the the visibility of the exit sign to the north obstructed by other signage.

4. The 2nd floor 1980 building Mechanical room is provided with three exits. However, due to low height ductwork and equipment arrangement, clear pathways to the exits are not obvious to occupants or identified.

5. The 2nd floor 1957 building Endoscopy area double egress cross corridor doors have the exit sign on the north side of the doors located over the door swinging against egress travel rather than the door intended for egress.

6. The 1st floor 1927 building Library lacks exit signage at each side of the door between the office area and the stack area to identify the second required exit path from the suite.

7. The 1st floor corridor northwest of the Lab directs the corridor exit path through the Lab suite in non-compliance with 7.5.1.2.

8. The 1st floor 3-hour door near Elevator #5 is not marked as a required exit path. A dead end corridor condition exists.

9. The Ground floor 1980 building west corridor serving Nuclear Medicine and EEG was not provided with exit signage at the north end to identify the required second path.

10. The Ground floor corridor south of the Kitchen serving Conference room #4 does not have exit signage to identify the path when moving east.

11. The exit sign at the 1957 building elevator machine room stair door is not illuminated.

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Based on random observation during the survey walk through, not all areas of the building fire alarm system are installed in accordance with NFPA-72 (1999).

Findings include:

1. No fire alarm notification devices were installed on the 4th floor Elevator Lobby corridor between the cross corridor fire and smoke barrier doors.

2. Audibility of the fire alarm system notification devices in the Dining room/confernce room #2/#3 was difficult to hear.


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3. No audible or visual alarms could be seen or heard in the east side lobby on the first and second floors for elevators one, two and three as required by NFPA-101, Section 9.6.3.

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Based on random observation during the survey walk-through on the afternoon of 10/11/11 or on 10/12/11, not all portions of the facility's wet sprinkler system are installed in accordance with NFPA 13 1999. These deficiencies could reduce the prompt activation or the effectiveness of the sprinkler system in the event of a fire condition. The buildings are to be considered fully sprinkler protected.

Findings include:

A. The 4th floor 1980 building Patient Transport room small closet containing the nurse call terminal is not provided with sprinkler protection to comply with NFPA 13-1999, 5-1.1(1).

B. The 4th floor 1927 building Pharmacy area contains rolling shelving units where the backs of the shelving units extend within 18" of the sprinkler head to form an obstrcution to the sprinkler spray pattern in non-compliance with 5-8.5.2.3.

C. The 1st floor Lobby Gift Shop is provided with a slat-board ceiling which could not be confirmed to be resistant to the passage of heat and smoke to effect activation of the sprinkler and smoke detection devices.

D. The 1st floor small Lab Equipment room located outside the Lab suite is not provided with a ceiling. The sidewall sprinkler head is located greater than 4' from the deck above in non-compliance with 5-9.4.1.1.

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E. Based on direct observation 10/12/11, the facility failed to provide automatic sprinkler protection for the following areas. These deficiencies compromise the safety of all occupants and does not allow for fire suppression and alarm to the facility:

1. The basement elevator machine room for Elevator No. 5 (NFPA 13, 1999, 5-13.6)

2. The morgue and body holding cooler (NFPA 13, 1999, 5-1.1)

3. The lowest level of Stair No. 8 (NFPA 13, 1999, 5-13.3.2)

4. 1980 Building patient sleeping room wardrobes (NFPA 13, 1999, 5-1.1)

5. Chapel closet with open ceiling to the unprotected space above (NFPA 13, 1999, 5-1.1)

6. The receiving and loading dock (NFPA 13, 1999, 5-13.8.2)

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Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

F. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7.

G. The fire pump room does not have a battery operated emergency light as required by NFPA 20-2-7.4.

H. The transfer switch for the fire pump is not located at the pump location as required by NFPA 20-6-6.4.

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By direct observation the facility failed to provide:

Identification of service openings for installed fire dampers. (NFPA 90A, 1999, 2-3.4.2)


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By direct observation 10/12/11 and document review 10/11/11, the surveyor finds the facility failed to provide complete fire suppression system inspections for three of three kitchen hood systems. The outside service company's 6 months inspections are documented however monthly inspection by the facility is not being completed and recorded. Impairment of these systems can affect the safety of patients, staff and visitors by delaying alarm and fire extinguishment. (NFPA 17, 1998, 9.2 (dry chemical systems) & 17A, 1998, 5.2 (wet chemical systems)

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. Medical gas tanks were observed being stored in the Sleep Lab room which provides access to the attic that are less than 5'-0" from combustibles not in compliance with NFPA 99 1999 8-3.1.11.2(c)(2). This deficiency could affect all occupants of the facility because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials.

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. Medical gas tanks were observed being stored with combustibles within 5'-0" not in compliance with NFPA 99 1999 8-3.1.11.2(c)(2). This deficiency could affect all occupants of the smoke compartment they are located in because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials. Locations observed include but are not necessarily limited to the following:

1. At the 4th floor 1980 building area Patient Transport storage room.

2. At the 1st floor Lab Equipment room within the Lab suite along the west corridor/aisle.

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A. Based on direct observation 10/12/11, the facility failed to install the medical air compressor intake per NFPA 99, 1999, 4-3.1.1.9. (b). These deficiencies allow for possible contamination of the breathable medical air system and putting patients at risk needing respiratory assistance:

1. The intake is not installed above the roof

2. The intake is constructed using PVC pipe as prohibited by 4-3.2.2.2 (a)


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Based on random observationduring the survey walk-through the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised without the facility being aware that the emergency generators are not functioning properly.

Findings include:

1. The 250 KW emergency generator did not have a remote annunciator to meet the requirements of NFPA-99, Section 3-4.1.1.15 and NFPA-110, Section 3-5.5.2(d).

2. The 250 KW and the 900 KW generators were not equipped with remote emergency shut-down switches to comply with NFPA-110, Section 3-5.5.6.

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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute 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.

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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

1.The emergency panels in older north part of the building are not separated by branch as required by NFPA 70, Section 517-30 through 35.

2. The newer south end of the building had life safety, critical and equipment transfer switches, but the critical and life safety loads were mixed in most panels such as panel EMB in the lab area. This does not meet the requirements of NFPA70, Section 517-30 through 35.

3. The fire alarm circuit breakers in the Life Safety Panels were not marked red and have a locking device on the breakers to comply with NFPA-72, Section 1-5.2.5.

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Based on random observation during the survey walk-through on the afternoon of 10/12/11, not all portions of the facility's electrical distribution system are in accordance with NFPA 70 1999.

Findings include:

A. The RPI and HP electrical panels located in the sprinkler system riser room were observed not to have all circuit breakers identified as to their use in accordance with NFPA 70-1999, 384-13. This deficiency could prevent proper identification of a circuit supplying power to an area required to be discontinued in the event of an emergency.

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Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999). Improper grounding could create a shock hazard for all occupants of the building.

Findings include:

1. Staff was not able to locate where the med gas piping was bonded as required by NFPA-70, Section 250.104(c).

2. Duplex receptacles served by emergency power in the C-Section room, the ICU rooms and several other critical care areas are not properly labeled in accordance with NFPA-70, Section 517-19(a).

3. The main water service entrance in the fire pump room was not grounded in accordance with NFPA-70, Section 250-50.

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Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

1. The surveyor observed that the elevator machine rooms were equipped with sprinklers, but there was not a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3. No shunt trip devices were installed on elevator disconnects.

2. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation as required by NFPA-70, Section 620-53.

3. The three elevator doors that open into the equipment room on the third floor were not equipped with a smoke detector tied to the elevator recall system as required by ASME A17.1-211.3b.

4. The surveyor did not observe and staff was unable to verify that the elevators were equipped with fire fighter's service as required by NFPA 101, Section 9.4.3.2, and ANSI A17.3, Rule 211.3.

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