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Based on random observation during the survey walk-through, the buildings are not properly separated from each other. This deficiency could affect all patients, as well as staff and visitors due to required fire resistive separation requirements that are not functioning correctly to prevent the spread of fire from building to building.

Findings include;

A. On 12/11/13 at 10:30am, the 2 hour fire barrier double doors located in the building connecting links did not properly coordinate to close.

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. On 12/12/13 At 11:00 AM Wing D Main Level, Atrium it was observed that rust had formed on a structural steel column which forms part of the roof structure and curtain wall construction. The applied intumescent fire proofing on the column is damaged. The applied fireproofing contains bubbles and sags. This does not comply with 19.1.6.2.

B. On 12/11/13 At 10:45 AM Wing E basement storage room (adjacent to the tunnel) contains a ceiling construction composed of unprotected bitumen, concrete and rubble. The unprotected bitumen does not comply with 19.1.6.2 and NFPA 220 for a material which constitutes a noncombustible construction type. A listed fire resistant design detail for the floor construction was not available.

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, 18.1.6.2, 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. On 12/9/2013 at 2:30 PM Wing T sixth floor West mechanical room it was observed that spray applied foam insulation had been applied to the spray on fire proofing located on the structural members. During an interview held with facility representatives the U.L. listed design for this application could not be determined to comply with 18.1.6.2 for a spray on insulation application over a spray on fireproofing application or in lieu of the original spray on fireproofing.

Based on observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or any occupied rooms.

Findings include:

A. On 12/12/13 at 9:15AM Wing C Third floor,ICU Corridor access doors from the ICU contain automatic locking devices which didunlock, however did not latch under fire alarm conditions which does not comply with 19.2.2.2.2 and 19.3.6.3.2.


B. On 12/12/13 at 9:15AM Wing C Third floor,ICU Corridor access doors from the ICU contain locking corridor doors that lacked a 15 second delay egress mechanism and do not comply with 19.2.2.2.2

C. On 12/11/13 at 2:30PM Wing A, third floor, Corridor access doors from the education suite do not comply with 19.3.6.3.2. Doors that were observed are bifold doors which lack latching hardware and levered handles.

Based on random observation and staff interview during the survey walk-through, not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels.

A. On 12/09/13 at 3:00PM Wing C, Mechanical room contains access doors to glazed enclosures for rooftop skylights. These access doors form noncompliant communicating spaces between floor levels. This condition does not maintain the fire resistant barrier between the floor below and the mechanical floor level. The doors do not comply with 8.2.3.1.2 and 8.2.3.2.1 for fire door requirements.

B. On 12/10/13 at 1:25PM The sliding horizontal one hour fire rated barrier doors did not provide separation between the Atrium and the remainder of the building. During a test of the fire alarm system, all barrier doors at the atruim failed to close. Locations observed:

1. Main entry Atrium from Wing I and Wing 890

2. Main entry Atrium from Waiting 1D004

3. Second floor Atrium from Corridor 2D010

Based on random observation during the survey walk-through while accompanied by facility representatives not all shaft barriers were properly separated from the remainder of the building in accordance with 18.3.1.1 and 8.2.5. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to pass from a shaft to the adjacent spaces and from floor to floor if not properly separated.

Findings include:

A. On 12/10/2013 at 9:32 AM, it was determined that in Wing " T " , 4th floor, Gym 4T522 contained an access door to a shaft that was not self closing to comply with 8.2.5.2.

Based on an observation while accompanied by facility representatives it was determined that the facility failed to provide doors to the exit passage way with operational door hardware in accordance with the requirements of 19.2 and 7.1. These deficient practices could affect all patients, staff and visitors within the smoke compartment if an emergency egress route is not protected by properly functioning doors.

Findings include:
A. On 12/11/13 at 2:35 PM, observations determined that door hardware did not properly latch during the fire alarm testing. Example locations include:
1. " D " wing, 3rd floor, Recovery Suite, South Double doors across from OR #6.
2. " D " wing, 3rd floor, Recovery Suite, North Double doors across from OR #2.
3. " D " wing, 3rd floor, Recovery Suite, North Double Egress doors from Recovery Room 3D400 into Corridor 3D119.
4. " D " wing, 3rd floor, Surgical Admitting Suite 3D155, East Double doors to Corridor 3D200.

Based on random observation during the survey walk-through while accompanied by facility representatives not all 1-hour smoke barriers were properly separated from the remainder of the building in accordance with 18.3.7.3 and 8.3. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to pass from smoke zone to smoke zone during a fire emergency.

Findings include:

A. On 12/10/2013 at 10:00 AM, it was determined that in Wing " T " , 4th floor, elevator lobby 4T401Z, smoke barrier wall above the acoustical tile ceiling contained a 1¼ " hole located on each side of the wall that was not properly firestopped to comply with 8.3.2.

B. On 12/10/2013 at 10:09 AM, it was determined that in Wing " T " , 4th floor, inpatient lobby 4T448Z, smoke barrier wall located above the acoustical tile ceiling contained a 1 " flexible conduit extending from the wall 6-inches that did not have the end of the conduit properly firestopped to comply with 8.3.2.

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 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.

A. 12/11/13 at 2:15PM Wing C 3rd floor Surgery Sterile Core contains numerous shelves and material storage and it is not designated as a hazardous area to comply with 8.4.1. It does have perimeter smoke tight walls however doors to O.R.'s were observed without a means for maintaining a closed position to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

B. 12/10/13 at 10:10AM Wing C thrid floor, in the Surgery corridor near the Control Station, the patient holding area (as designated by the licensing act) was being used for staff charting and for equipment storage. The area used as storage was observed open to the exit access corridor.





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Based on random observation during the survey walk-through while accompanied by facility representatives not all hazardous areas were properly separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor during a fire emergency.

Findings include:

C. On 12/11/13 at 10:50 AM, it was determined that in " C " wing, Basement, Kitchen, Food Storage Room OC114A contained a door that did not latch to the door frame when tested to comply with 19.3.2.1.

D. On 12/11/13 at 10:52 AM, it was determined that in " C " wing, Basement, Kitchen, Food Storage Room OC114 contained a door that was not self closing to comply with 19.3.2.1.



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E. On 12/10/13 at 12:59 PM Wing D, Third floor, Janitor's Closet JD556 (in the Surgery corridor) was observed that the corridor door does not latch to comply with 19.3.2.1.

F On 12/10/13 at 1:09 PM Wing D, Third floor,Clean Utility 3D557 (in the Surgery corridor) was observed that the corridor door does not latch to comply with 19.3.2.1.

G. On 12/11/13 at 10:40 AM Wing E Basement Storage room (near tunnel) was observed that there are unprotected openings in the storage room walls.

H. On 12/11/13 at 10:40 AM Wing E Basement Storage room (near tunnel) a door to the tunnel was observed which lacks a fire resistant label, is not self closing, contains a hole through it and lacks hardware.

I. On 12/11/13 at 10:50AM Wing A, Stair M exterior exit path adjacent to the Loading dock contains combustible wooden pallets stacked along the means of egress.

Based on random observation during the survey walk-through while accompanied by facility representatives not all hazardous areas were properly separated from the remainder of the building in accordance with 18.3.2.1 and 8.4.1. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor during a fire emergency.

Findings include:

A. On 12/10/2013 at 10:14 AM, it was determined that in Wing " T " , 4th floor, Equipment Storage Room 4T422, wall above the acoustical tile ceiling contained a 1 " hole located on each side of the wall that was not smoke tight and did not comply with 8.2.4.1 and 8.4.1.2.

Based on observation during the survey walk-through while accompanied by facility representatives, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect all 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. On 12/09/13 at 2:45 PM Wing C Stair E 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. Exit Stair C "Center Building"

2. Exit Stair B

3. Exit Stair K

Based on random observation during the survey walk-through, while accompanied by facility representatives, the surveyor observed that not all exterior exit discharges are arranged or maintained to make clear the direction of egress to comply with 7.7.3. This deficient practice could affect patients, visitors and staff by delaying emergency exiting to a public way.

Findings include:

A. On 12/12/13 at 10:30AM At the first floor corridor leading to the IT building exterior exit paths were observed that do not comply with 7.7.1. and 7.7.3 The exterior path to the public way within the courtyard was not clear and unobstructed. The discharge paths were covered with snow. These paths serve Stairs F, K and H.


During the survey walk-through while accompanied by facility representatives the surveyor 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:

B. At 10:57 AM on 12/10/13 at the ICU Suite located on the third floor of Wing C it was observed that exit signage directs the path of egress from the corridor serving the Elevator C lobby into the ICU Suite. 19.2.5.9

C. At 2:05 PM on 12/11/13 at the Pediatric Suite on the second floor of Wing A it was observed that delayed egress hardware is provided at the exit stair but it lacks the correct signage as required by 7.2.1.6.1.(d).

D. At 9:45 AM on 12/11/13 at the mechanical room located in the basement of Wing D it was observed that a guardrail is not provided at the lift adjacent to the egress stairs from the room. When the lift is lowered there is a drop greater than 30 inches at the stair landing. 7.2.2.4.1

From random 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 12/12/13 at 10:15AM Wing C Third floor, Recovery, Access to an exit is not provided from the Recovery suite due to signs on corridor access doors which read " staff only doors must remain closed " and " stop " .


B. On 12/10/13 Wing C, Third floor, Surgery suite contains a sterile core with one designated means of egress which does not comply with 19.2.6.2.2 for a maximum travel distance of 200 feet from any point in a room to an exit. Due to the approximate distance of 110 feet to an exit access door within the core, there is no exit (horizontal, stair etc.) within 90 feet of the exit access door for this room.

Based on random observation during the survey walk-through while accompanied by facility representatives, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all patients, visitors and staff within the areas of the fire compartment, as well as any persons in the adjacent compartment, because failure to construct and maintain fire resistive assemblies could allow fire and smoke to pass from one compartment into adjacent fire/smoke compartments.

Findings include:

A. On 12/10/13 at 1:45PM Wing C 3rd floor ICU suite contains a designated 2 hour barrier wall that consists of a horizontal sliding door which does not operate under fire alarm conditions. The door failed to close in order to comply with 8.2.3.2.3.1





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B. On 12/10/13 At 10:10 AM Wing T and Wing A at the Third floor horizontal exit it was observed that doors in the horizontal exit which separate Wing T and Wing A are equipped with electric magnet locks. Staff was unable to verify that the locking mechanisms are permanently disabled, therefore this application for a lockable door does not comply with 19.2.2.2.4 and 7.2.4.2.3.

Based on random observation during the survey walk through while accompanied by the facility representative, light switches within the exit enclosure provided a manual means to discontinue illumination within a means of egress which does not comply with 7.8.1.2. This condition may prevent staff and visitors, within the exit stair, from a safe passage to an exit discharge

Findings include:

A. On12/11/13 at 11:00 AM Wing A Stair M 1st floor exit discharge located adjacent to the Loading Dock lacked the required amount of emergency illumination to comply with 7.8 so as not to leave an area in darkness. The exterior discharge lighting was observed to be powered from a wall switch within the discharge stair, therefore, the lighting does not appear to be on emergency power.

Based on random observation during the survey walk-through not all portions of the building are provided with emergency battery lighting. These deficiencies could affect all patients, as well as staff and visitors, who use this exit path in an emergency.

Findings include:

A. On 12/11/13 at 10:40am, an emergency battery backup light located at the reception desk of the imaging center failed when the test function was activated.

Based on random observation during the survey walk-through while accompanied by engineering staff, battery powered emergency illumination is not provided to comply with 19.2.9.1, 7.9 and NFPA 99-1999, 3-3.2.1.2 for locations of anesthetized patients. This deficiency could affect any patients, staff, or visitors on this floor level because the failure of the normal lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

All Wings:
A. Documents indicating yearly 90 minute testing of the emergency battery operated lighting were not provided. Facility representatives indicated they replace the batteries on annual bases therefore annual 90 minute test is not required. This battery replacement policy does not relieve the facility from the requirements of NFPA 101, 7.9.3.


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B. On 12/10/13 at 1:12PM Wing C 3rd floor Operating room #10 was observed to not be provided with battery powered emergency lighting to comply with NFPA 99-1999, 3-3.2.1.2(a)5(e). During an interview held with the Nurse Manager for the Surgery Dept. it was determined that none of the Operating Rooms contained battery powered emergency lighting.

Based on random observation during the survey walk-through not all exits in the building are properly identified. These deficiencies could affect all patients, as well as staff and visitors, who use this exit path in an emergency.

Findings include:

A.. On 12/11/13 at 11:05am, the front door of the PT is one of the facilities required exits. It is not identified as an exit with the proper signage.

During the survey walk-through while accompanied by facility representatives, the surveyor observed paths of egress that were not identified by exit signage to comply with 19.2.10.1 and 7.10.2. 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. During the survey walk throughs on 12/10/13, 12/11/13 and 12/12/13 Exit signs are not provided to identify the direction of egress from corridors or rooms to comply with 19.2.5.9, 19.2.10.1, and 7.10.2. Locations noted include the following:

1. At 10:20 AM on 12/10/13 at the north end of the third floor of Wing A second direction of egress is not identified by exit signage at the west end of the corridor serving Stair M.

2. At 10:30 AM on 12/11/13 in the basement of Wing A near the morgue a second direction of egress is not identified by exit signage at the corridor serving Stair M. 19.2.5.9, 19.2.10.1

3. At 11:04 AM on 12/11/13 at the east end of the corridor from Wing I into Wing C a second direction of egress is not identified by exit signage. 19.2.5.9, 19.2.10.1

4. At 11:36 AM on 12/11/13 in the corridor adjacent to the pharmacy and lab in the basement of Wing C a second direction of egress is not identified by exit signage. 19.2.5.9, 19.2.10.1

5. At 8:58 AM on 12/12/13 in the corridor outside the MRI suite on the first floor of Wing C a second direction of egress is not identified by exit signage over the cross corridor doors. 19.2.5.9, 19.2.10.1

6. At 9:02 AM on 12/12/13 in the corridor outside Nuclear Medicine on the first floor of Wing C a second direction of egress is not identified by exit signage over door FD-C-L1-19. 19.2.5.9, 19.2.10.1

7. At 9:12 AM on 12/12/13 in the ICU suite located on the third floor of Wing C it was observed that exit signage is provided that indentifies a path of egress that is blocked by the WON-Door when it is deployed. 19.2.10.1

8. At 9:43 AM on 12/12/13 near the first floor lobby for the C elevators in Wing C a second direction of egress is not identified by exit signage over door FD-C-L1-5. 19.2.5.9, 19.2.10.1

B. At 8:43 AM on 12/12/13 at the first floor atrium located in Wing D it was observed that exit signage is provided which identifies a path of egress to the non operable side of the WON-Door when it is deployed. This does not comply with 19.2.10.1

Based on observation during the surveyor walk through while accompanied by the facility representatives, the facility failed to provide a fire alarm system with components, devices or equipment installed to comply with NFPA 72. This deficieint practice would affect patients, visitors and staff within A Wing and C Wing, from safely progressing to an adjacent fire compartment during a fire/smoke event.

Findings include:

A. On 12/10/13 at 10:50 AM Wing A, third floor by direct observation a fire alarm pull station is not provided at both sides of a pair of cross corridor doors at a horizontal exit which does not comply with 19.3.4.1 and NFPA 72 1999 Ed. 2-8.2.2.

B. On 12/11/13 at 2:40PM Wing D, first floor Atrium, by direct observation from a single location more than two strobe annunciators are visible which are not synchronized to comply with NFPA 72 1999 Ed. 4-4.4.2.3.

Based on random 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


A. Based on direct observation the morning of 12/10/13 while in the company of the manager of facilities operations, the chief engineer and the lead electrician the surveyor finds that the facility failed to provide sprinkler fire protection for th Sump Pump closet (0C053) located in Linen Chute room (0C054).
1. C Wing Basement



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B. On 12/11/13 at 11:00 AM Wing C, Basement Level, Lab work room #0C085 (a closet) was observed which is not provided with sprinkler protection in a building which is otherwise considered fully protected.

A. Based on direct observation the afternoon of 12/10/13 while in the company of the manager of facilities operations, the safety officer, the chief engineer and the lead electrician the surveyors find the facility grease duct installation for the cafeteria grill is not installed in compliance with NFPA 96, 1998:

C Wing 2nd Floor:

1. The installation is provided with a damper as the duct leaves the shaft on the second floor as prohibited by NFPA 96, 6-1.

2. Access to the above damper is by way of a non-compliant access door. NFPA 96, 4-3.4.4.

3. The duct is constructed with bolted flanges and not seamless weld as required by NFPA 96, 4-5.2.1. there is evidence of leakage at these flanged joints.

4. A continuous shaft enclosure from the hood to the exterior is not provided. NFPA 96, 4-7.1 By direct observation the duct exits the shaft above the ceiling of Nourishment Room (2C184) across the room exposed through the corridor wall then up through the floor above what looks to be a shaft enclosure. The duct as it enters the shaft is not sealed at this point leaving the shaft open to second floor.



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Based on an observation and interview while accompanied by facility representatives the facility failed to ensure that the kitchen staff was properly trained on the use of the range hood (ANSUL) fire extinguishing system per NFPA 96, section 8-1.4. missing identifying placard for portable fire extinguishers per NFPA 96, section 7-2.1.1. , NFPA 10, section 2-3.2.1 and missing nozzle protective inserts per NFPA 17A, section 2-3.1.4. These deficient practices could affect all patients, staff and visitors within the smoke compartment if fire and smoke from a kitchen fire was not contained properly.

Findings include:

B. On 12/11/13 at 10:40 AM, an observation determined that in the " C " wing, Basement, Kitchen contained (2) portable wall hung K-Type fire extinguisher and (2) ABC portable wall hung fire extinguishers that were not installed with the required identifying placard to comply with NFPA 10, section 2-3.2.1 and NFPA 96, section 7-2.1.1

C. On 12/11/13 at 10:53 AM, an Interview with Kitchen staff members determined that they have not been in-serviced regarding the proper sequence for activating the ANSUL hood extinguishing system and the use of the K-Type kitchen portable fire extinguisher if there was a fire at the cooking surface to comply with 19.7.1.3.

D. On 12/11/13 at 10:53 AM, an observation determined that in the " C " wing, Basement, Kitchen, ANSUL Hood extinguishing system contained (7) nozzles and it was determined that (1) nozzle was missing the foil protector to comply with NFPA 17A, section 2-3.1.4.

A. Based on direct observation the morning of 12/10/13 while in the company of the manager of facilities operations, the chief engineer and the lead electrician the surveyor finds that the limited access linen and trash chutes are not maintained in the locked position as required by NFPA 82, 1999, 3-2.4.2 & 3-24.3.2.

1. Wing A all floors

Based on observations during the survey walk- through, while accompanied by the facility representative, the facility failed to maintain the means of egress corridors free from obstructions to comply with 7.1.10. This condition could affect patients, visitors and staff from gaining access to an exit in a timely manner during a fire/smoke event.

Findings include:

A. During the morning and afternoon of 12/10/13, 12/11/13 and 12/12/13 means of egress corridors were observed to be used as storage for wheelchairs, computers-on wheels, IV stands, carts and chairs. The length of egress corridors were reduced to half their required width which does not comply with 19.2.1 and 7/1/10. Example locations observed:
1. Wing A second through fourth floors
2. Wing C second through fourth floors
3. Wing D corridor adjacent to the Operating Room suite.

B. On 12/11/13 at 1:45pm a means of egress corridor was observed containing furniture which obstructed access to the operating hardware of a horizontal sliding cross corridor door which does not comply with 19.2.1 and 7.1.10. Location observed:

1. Wing D, first floor, Corridor 1D200 Won-style door leading to the Atrium.



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C. On 12/11/13 at 11:15 AM, an observation determined that in " C " wing, Basement, Serving Area OC093 adjacent to the Kitchen contained (2) sliding wire gates that are locked in the closed position after 10:00 PM each day and not unlocked until the next morning. An observation noted that an exit sign was placed at each of the gate locations. An interview with the Dietary Manager and an observation determined that within the kitchen a door to the serving line space was installed with an exit sign indicating that this was a path to an emergency exit. If individuals were to use the kitchen emergency egress door leading to the gated serving area they would become trapped and unable to exit this space which does not comply with 19.2.2.2.4.

A. Based on direct observation the morning of 12/10/13 while in the company of the manager of facilities operations, the chief engineer and the lead electrician, the surveyor finds that the Medical Gas Storage room (0A043) contains cylinder storage in excess 3000 cubic feet is naturally vented to the outside however the door from Mechanical Room (0A042) was blocked in the open position not providing the separation required by NFPA 99, 1999, 4-3.1.1.2.

1. A Wing Basement:

A. Due to 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.

Based on observations during the survey walk-through, the facility failed to store flammable and combustible liquids in accordance with 19.3.2.1 and NFPA 99 1999 10-7.2.1. This deficiency could affect all staff members using the surrounding laboratory in the event of a spill or fire.

Findings include:

A. At 11:23 AM on 12/11/13 Wing C, Basement, Laboratory Storeroom 0C134 bottles of toxic chemicals were observed stored within their required cabinets, however, the waste Xylene and Achohol bottles were stored on their sides laying on top of bottles within already filled shelves which does not comply with 19.3.2.1, NFPA 99 1999 Ed. 10-7.2.1.

A. Based on direct observation the morning of 12/10/13 while in the company of the manager of facilities operations, the chief engineer and the lead electrician the surveyor finds that the identified emergency electrical panels are not identified as life safety, critical or equipment and the they contain a mixture of circuits all three branches of the essential electrical system in non compliance with NFPA 70, 1999, 517-32, 33 & 34, NFPA 99, 1999, 3-4.2.2.2 & 4-4.2.2.3. This condition exists throughout the A Wing on all floors.


1. Wing A, 4th floor:

A. Based on direct observation and staff interview the morning of 12/11/13 while in the company of the manager of facilities operations, the chief engineer and the lead electrician the surveyor finds while at the Med Gas Manifold Room 1E099 it could not be identified that the metal pipe systems connected to the manifolds are bonded as required by NFPA 70 1999 250-2(c).


1. Wing E, 1st Floor :

A. Based on direct observation the morning of 12/12/13 while in the company of the manager of facilities operations & the chief engineer, the surveyor finds that Elevator Recall is provided for Elevators C1, C2, and separate recall is provided for C3, C4. Elevators C1 & C2 are not installed in the same shaft as Elevators C3 & C4. These four elevators are not separated at the penthouse machine room therefore joining the two shafts. Further, C1 & C2 and C3 & C4 Elevators Lobbies are not separated on all floors. During fire alarm testing it was noted that C1 & C2 recall when their dedicated smoke detectors are activated, however C3 & C4 do not. C3 & C4 recall when their dedicated smoke detectors are activated however C1 & C2 do not. These four elevators share the same shaft by way of machine room and lobbies and must recall together as required by ANSI A17.3.

1. Wing C.

Based on random observation during the survey walk-through, the buildings are not properly separated from each other. This deficiency could affect all patients, as well as staff and visitors due to required fire resistive separation requirements that are not functioning correctly to prevent the spread of fire from building to building.

Findings include;

A. On 12/11/13 at 10:30am, the 2 hour fire barrier double doors located in the building connecting links did not properly coordinate to close.

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. On 12/12/13 At 11:00 AM Wing D Main Level, Atrium it was observed that rust had formed on a structural steel column which forms part of the roof structure and curtain wall construction. The applied intumescent fire proofing on the column is damaged. The applied fireproofing contains bubbles and sags. This does not comply with 19.1.6.2.

B. On 12/11/13 At 10:45 AM Wing E basement storage room (adjacent to the tunnel) contains a ceiling construction composed of unprotected bitumen, concrete and rubble. The unprotected bitumen does not comply with 19.1.6.2 and NFPA 220 for a material which constitutes a noncombustible construction type. A listed fire resistant design detail for the floor construction was not available.

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, 18.1.6.2, 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. On 12/9/2013 at 2:30 PM Wing T sixth floor West mechanical room it was observed that spray applied foam insulation had been applied to the spray on fire proofing located on the structural members. During an interview held with facility representatives the U.L. listed design for this application could not be determined to comply with 18.1.6.2 for a spray on insulation application over a spray on fireproofing application or in lieu of the original spray on fireproofing.

Based on observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or any occupied rooms.

Findings include:

A. On 12/12/13 at 9:15AM Wing C Third floor,ICU Corridor access doors from the ICU contain automatic locking devices which didunlock, however did not latch under fire alarm conditions which does not comply with 19.2.2.2.2 and 19.3.6.3.2.


B. On 12/12/13 at 9:15AM Wing C Third floor,ICU Corridor access doors from the ICU contain locking corridor doors that lacked a 15 second delay egress mechanism and do not comply with 19.2.2.2.2

C. On 12/11/13 at 2:30PM Wing A, third floor, Corridor access doors from the education suite do not comply with 19.3.6.3.2. Doors that were observed are bifold doors which lack latching hardware and levered handles.

Based on random observation and staff interview during the survey walk-through, not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels.

A. On 12/09/13 at 3:00PM Wing C, Mechanical room contains access doors to glazed enclosures for rooftop skylights. These access doors form noncompliant communicating spaces between floor levels. This condition does not maintain the fire resistant barrier between the floor below and the mechanical floor level. The doors do not comply with 8.2.3.1.2 and 8.2.3.2.1 for fire door requirements.

B. On 12/10/13 at 1:25PM The sliding horizontal one hour fire rated barrier doors did not provide separation between the Atrium and the remainder of the building. During a test of the fire alarm system, all barrier doors at the atruim failed to close. Locations observed:

1. Main entry Atrium from Wing I and Wing 890

2. Main entry Atrium from Waiting 1D004

3. Second floor Atrium from Corridor 2D010

Based on random observation during the survey walk-through while accompanied by facility representatives not all shaft barriers were properly separated from the remainder of the building in accordance with 18.3.1.1 and 8.2.5. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to pass from a shaft to the adjacent spaces and from floor to floor if not properly separated.

Findings include:

A. On 12/10/2013 at 9:32 AM, it was determined that in Wing " T " , 4th floor, Gym 4T522 contained an access door to a shaft that was not self closing to comply with 8.2.5.2.

Based on an observation while accompanied by facility representatives it was determined that the facility failed to provide doors to the exit passage way with operational door hardware in accordance with the requirements of 19.2 and 7.1. These deficient practices could affect all patients, staff and visitors within the smoke compartment if an emergency egress route is not protected by properly functioning doors.

Findings include:
A. On 12/11/13 at 2:35 PM, observations determined that door hardware did not properly latch during the fire alarm testing. Example locations include:
1. " D " wing, 3rd floor, Recovery Suite, South Double doors across from OR #6.
2. " D " wing, 3rd floor, Recovery Suite, North Double doors across from OR #2.
3. " D " wing, 3rd floor, Recovery Suite, North Double Egress doors from Recovery Room 3D400 into Corridor 3D119.
4. " D " wing, 3rd floor, Surgical Admitting Suite 3D155, East Double doors to Corridor 3D200.

Based on random observation during the survey walk-through while accompanied by facility representatives not all 1-hour smoke barriers were properly separated from the remainder of the building in accordance with 18.3.7.3 and 8.3. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to pass from smoke zone to smoke zone during a fire emergency.

Findings include:

A. On 12/10/2013 at 10:00 AM, it was determined that in Wing " T " , 4th floor, elevator lobby 4T401Z, smoke barrier wall above the acoustical tile ceiling contained a 1¼ " hole located on each side of the wall that was not properly firestopped to comply with 8.3.2.

B. On 12/10/2013 at 10:09 AM, it was determined that in Wing " T " , 4th floor, inpatient lobby 4T448Z, smoke barrier wall located above the acoustical tile ceiling contained a 1 " flexible conduit extending from the wall 6-inches that did not have the end of the conduit properly firestopped to comply with 8.3.2.

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 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.

A. 12/11/13 at 2:15PM Wing C 3rd floor Surgery Sterile Core contains numerous shelves and material storage and it is not designated as a hazardous area to comply with 8.4.1. It does have perimeter smoke tight walls however doors to O.R.'s were observed without a means for maintaining a closed position to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

B. 12/10/13 at 10:10AM Wing C thrid floor, in the Surgery corridor near the Control Station, the patient holding area (as designated by the licensing act) was being used for staff charting and for equipment storage. The area used as storage was observed open to the exit access corridor.





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Based on random observation during the survey walk-through while accompanied by facility representatives not all hazardous areas were properly separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor during a fire emergency.

Findings include:

C. On 12/11/13 at 10:50 AM, it was determined that in " C " wing, Basement, Kitchen, Food Storage Room OC114A contained a door that did not latch to the door frame when tested to comply with 19.3.2.1.

D. On 12/11/13 at 10:52 AM, it was determined that in " C " wing, Basement, Kitchen, Food Storage Room OC114 contained a door that was not self closing to comply with 19.3.2.1.



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E. On 12/10/13 at 12:59 PM Wing D, Third floor, Janitor's Closet JD556 (in the Surgery corridor) was observed that the corridor door does not latch to comply with 19.3.2.1.

F On 12/10/13 at 1:09 PM Wing D, Third floor,Clean Utility 3D557 (in the Surgery corridor) was observed that the corridor door does not latch to comply with 19.3.2.1.

G. On 12/11/13 at 10:40 AM Wing E Basement Storage room (near tunnel) was observed that there are unprotected openings in the storage room walls.

H. On 12/11/13 at 10:40 AM Wing E Basement Storage room (near tunnel) a door to the tunnel was observed which lacks a fire resistant label, is not self closing, contains a hole through it and lacks hardware.

I. On 12/11/13 at 10:50AM Wing A, Stair M exterior exit path adjacent to the Loading dock contains combustible wooden pallets stacked along the means of egress.

Based on random observation during the survey walk-through while accompanied by facility representatives not all hazardous areas were properly separated from the remainder of the building in accordance with 18.3.2.1 and 8.4.1. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor during a fire emergency.

Findings include:

A. On 12/10/2013 at 10:14 AM, it was determined that in Wing " T " , 4th floor, Equipment Storage Room 4T422, wall above the acoustical tile ceiling contained a 1 " hole located on each side of the wall that was not smoke tight and did not comply with 8.2.4.1 and 8.4.1.2.

Based on observation during the survey walk-through while accompanied by facility representatives, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect all 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. On 12/09/13 at 2:45 PM Wing C Stair E 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. Exit Stair C "Center Building"

2. Exit Stair B

3. Exit Stair K

Based on random observation during the survey walk-through, while accompanied by facility representatives, the surveyor observed that not all exterior exit discharges are arranged or maintained to make clear the direction of egress to comply with 7.7.3. This deficient practice could affect patients, visitors and staff by delaying emergency exiting to a public way.

Findings include:

A. On 12/12/13 at 10:30AM At the first floor corridor leading to the IT building exterior exit paths were observed that do not comply with 7.7.1. and 7.7.3 The exterior path to the public way within the courtyard was not clear and unobstructed. The discharge paths were covered with snow. These paths serve Stairs F, K and H.


During the survey walk-through while accompanied by facility representatives the surveyor 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:

B. At 10:57 AM on 12/10/13 at the ICU Suite located on the third floor of Wing C it was observed that exit signage directs the path of egress from the corridor serving the Elevator C lobby into the ICU Suite. 19.2.5.9

C. At 2:05 PM on 12/11/13 at the Pediatric Suite on the second floor of Wing A it was observed that delayed egress hardware is provided at the exit stair but it lacks the correct signage as required by 7.2.1.6.1.(d).

D. At 9:45 AM on 12/11/13 at the mechanical room located in the basement of Wing D it was observed that a guardrail is not provided at the lift adjacent to the egress stairs from the room. When the lift is lowered there is a drop greater than 30 inches at the stair landing. 7.2.2.4.1

From random 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 12/12/13 at 10:15AM Wing C Third floor, Recovery, Access to an exit is not provided from the Recovery suite due to signs on corridor access doors which read " staff only doors must remain closed " and " stop " .


B. On 12/10/13 Wing C, Third floor, Surgery suite contains a sterile core with one designated means of egress which does not comply with 19.2.6.2.2 for a maximum travel distance of 200 feet from any point in a room to an exit. Due to the approximate distance of 110 feet to an exit access door within the core, there is no exit (horizontal, stair etc.) within 90 feet of the exit access door for this room.

Based on random observation during the survey walk-through while accompanied by facility representatives, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all patients, visitors and staff within the areas of the fire compartment, as well as any persons in the adjacent compartment, because failure to construct and maintain fire resistive assemblies could allow fire and smoke to pass from one compartment into adjacent fire/smoke compartments.

Findings include:

A. On 12/10/13 at 1:45PM Wing C 3rd floor ICU suite contains a designated 2 hour barrier wall that consists of a horizontal sliding door which does not operate under fire alarm conditions. The door failed to close in order to comply with 8.2.3.2.3.1





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B. On 12/10/13 At 10:10 AM Wing T and Wing A at the Third floor horizontal exit it was observed that doors in the horizontal exit which separate Wing T and Wing A are equipped with electric magnet locks. Staff was unable to verify that the locking mechanisms are permanently disabled, therefore this application for a lockable door does not comply with 19.2.2.2.4 and 7.2.4.2.3.

Based on random observation during the survey walk through while accompanied by the facility representative, light switches within the exit enclosure provided a manual means to discontinue illumination within a means of egress which does not comply with 7.8.1.2. This condition may prevent staff and visitors, within the exit stair, from a safe passage to an exit discharge

Findings include:

A. On12/11/13 at 11:00 AM Wing A Stair M 1st floor exit discharge located adjacent to the Loading Dock lacked the required amount of emergency illumination to comply with 7.8 so as not to leave an area in darkness. The exterior discharge lighting was observed to be powered from a wall switch within the discharge stair, therefore, the lighting does not appear to be on emergency power.

Based on random observation during the survey walk-through not all portions of the building are provided with emergency battery lighting. These deficiencies could affect all patients, as well as staff and visitors, who use this exit path in an emergency.

Findings include:

A. On 12/11/13 at 10:40am, an emergency battery backup light located at the reception desk of the imaging center failed when the test function was activated.

Based on random observation during the survey walk-through while accompanied by engineering staff, battery powered emergency illumination is not provided to comply with 19.2.9.1, 7.9 and NFPA 99-1999, 3-3.2.1.2 for locations of anesthetized patients. This deficiency could affect any patients, staff, or visitors on this floor level because the failure of the normal lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

All Wings:
A. Documents indicating yearly 90 minute testing of the emergency battery operated lighting were not provided. Facility representatives indicated they replace the batteries on annual bases therefore annual 90 minute test is not required. This battery replacement policy does not relieve the facility from the requirements of NFPA 101, 7.9.3.


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B. On 12/10/13 at 1:12PM Wing C 3rd floor Operating room #10 was observed to not be provided with battery powered emergency lighting to comply with NFPA 99-1999, 3-3.2.1.2(a)5(e). During an interview held with the Nurse Manager for the Surgery Dept. it was determined that none of the Operating Rooms contained battery powered emergency lighting.

Based on random observation during the survey walk-through not all exits in the building are properly identified. These deficiencies could affect all patients, as well as staff and visitors, who use this exit path in an emergency.

Findings include:

A.. On 12/11/13 at 11:05am, the front door of the PT is one of the facilities required exits. It is not identified as an exit with the proper signage.

During the survey walk-through while accompanied by facility representatives, the surveyor observed paths of egress that were not identified by exit signage to comply with 19.2.10.1 and 7.10.2. 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. During the survey walk throughs on 12/10/13, 12/11/13 and 12/12/13 Exit signs are not provided to identify the direction of egress from corridors or rooms to comply with 19.2.5.9, 19.2.10.1, and 7.10.2. Locations noted include the following:

1. At 10:20 AM on 12/10/13 at the north end of the third floor of Wing A second direction of egress is not identified by exit signage at the west end of the corridor serving Stair M.

2. At 10:30 AM on 12/11/13 in the basement of Wing A near the morgue a second direction of egress is not identified by exit signage at the corridor serving Stair M. 19.2.5.9, 19.2.10.1

3. At 11:04 AM on 12/11/13 at the east end of the corridor from Wing I into Wing C a second direction of egress is not identified by exit signage. 19.2.5.9, 19.2.10.1

4. At 11:36 AM on 12/11/13 in the corridor adjacent to the pharmacy and lab in the basement of Wing C a second direction of egress is not identified by exit signage. 19.2.5.9, 19.2.10.1

5. At 8:58 AM on 12/12/13 in the corridor outside the MRI suite on the first floor of Wing C a second direction of egress is not identified by exit signage over the cross corridor doors. 19.2.5.9, 19.2.10.1

6. At 9:02 AM on 12/12/13 in the corridor outside Nuclear Medicine on the first floor of Wing C a second direction of egress is not identified by exit signage over door FD-C-L1-19. 19.2.5.9, 19.2.10.1

7. At 9:12 AM on 12/12/13 in the ICU suite located on the third floor of Wing C it was observed that exit signage is provided that indentifies a path of egress that is blocked by the WON-Door when it is deployed. 19.2.10.1

8. At 9:43 AM on 12/12/13 near the first floor lobby for the C elevators in Wing C a second direction of egress is not identified by exit signage over door FD-C-L1-5. 19.2.5.9, 19.2.10.1

B. At 8:43 AM on 12/12/13 at the first floor atrium located in Wing D it was observed that exit signage is provided which identifies a path of egress to the non operable side of the WON-Door when it is deployed. This does not comply with 19.2.10.1

Based on observation during the surveyor walk through while accompanied by the facility representatives, the facility failed to provide a fire alarm system with components, devices or equipment installed to comply with NFPA 72. This deficieint practice would affect patients, visitors and staff within A Wing and C Wing, from safely progressing to an adjacent fire compartment during a fire/smoke event.

Findings include:

A. On 12/10/13 at 10:50 AM Wing A, third floor by direct observation a fire alarm pull station is not provided at both sides of a pair of cross corridor doors at a horizontal exit which does not comply with 19.3.4.1 and NFPA 72 1999 Ed. 2-8.2.2.

B. On 12/11/13 at 2:40PM Wing D, first floor Atrium, by direct observation from a single location more than two strobe annunciators are visible which are not synchronized to comply with NFPA 72 1999 Ed. 4-4.4.2.3.

Based on random 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


A. Based on direct observation the morning of 12/10/13 while in the company of the manager of facilities operations, the chief engineer and the lead electrician the surveyor finds that the facility failed to provide sprinkler fire protection for th Sump Pump closet (0C053) located in Linen Chute room (0C054).
1. C Wing Basement



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B. On 12/11/13 at 11:00 AM Wing C, Basement Level, Lab work room #0C085 (a closet) was observed which is not provided with sprinkler protection in a building which is otherwise considered fully protected.

A. Based on direct observation the afternoon of 12/10/13 while in the company of the manager of facilities operations, the safety officer, the chief engineer and the lead electrician the surveyors find the facility grease duct installation for the cafeteria grill is not installed in compliance with NFPA 96, 1998:

C Wing 2nd Floor:

1. The installation is provided with a damper as the duct leaves the shaft on the second floor as prohibited by NFPA 96, 6-1.

2. Access to the above damper is by way of a non-compliant access door. NFPA 96, 4-3.4.4.

3. The duct is constructed with bolted flanges and not seamless weld as required by NFPA 96, 4-5.2.1. there is evidence of leakage at these flanged joints.

4. A continuous shaft enclosure from the hood to the exterior is not provided. NFPA 96, 4-7.1 By direct observation the duct exits the shaft above the ceiling of Nourishment Room (2C184) across the room exposed through the corridor wall then up through the floor above what looks to be a shaft enclosure. The duct as it enters the shaft is not sealed at this point leaving the shaft open to second floor.



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Based on an observation and interview while accompanied by facility representatives the facility failed to ensure that the kitchen staff was properly trained on the use of the range hood (ANSUL) fire extinguishing system per NFPA 96, section 8-1.4. missing identifying placard for portable fire extinguishers per NFPA 96, section 7-2.1.1. , NFPA 10, section 2-3.2.1 and missing nozzle protective inserts per NFPA 17A, section 2-3.1.4. These deficient practices could affect all patients, staff and visitors within the smoke compartment if fire and smoke from a kitchen fire was not contained properly.

Findings include:

B. On 12/11/13 at 10:40 AM, an observation determined that in the " C " wing, Basement, Kitchen contained (2) portable wall hung K-Type fire extinguisher and (2) ABC portable wall hung fire extinguishers that were not installed with the required identifying placard to comply with NFPA 10, section 2-3.2.1 and NFPA 96, section 7-2.1.1

C. On 12/11/13 at 10:53 AM, an Interview with Kitchen staff members determined that they have not been in-serviced regarding the proper sequence for activating the ANSUL hood extinguishing system and the use of the K-Type kitchen portable fire extinguisher if there was a fire at the cooking surface to comply with 19.7.1.3.

D. On 12/11/13 at 10:53 AM, an observation determined that in the " C " wing, Basement, Kitchen, ANSUL Hood extinguishing system contained (7) nozzles and it was determined that (1) nozzle was missing the foil protector to comply with NFPA 17A, section 2-3.1.4.

A. Based on direct observation the morning of 12/10/13 while in the company of the manager of facilities operations, the chief engineer and the lead electrician the surveyor finds that the limited access linen and trash chutes are not maintained in the locked position as required by NFPA 82, 1999, 3-2.4.2 & 3-24.3.2.

1. Wing A all floors

Based on observations during the survey walk- through, while accompanied by the facility representative, the facility failed to maintain the means of egress corridors free from obstructions to comply with 7.1.10. This condition could affect patients, visitors and staff from gaining access to an exit in a timely manner during a fire/smoke event.

Findings include:

A. During the morning and afternoon of 12/10/13, 12/11/13 and 12/12/13 means of egress corridors were observed to be used as storage for wheelchairs, computers-on wheels, IV stands, carts and chairs. The length of egress corridors were reduced to half their required width which does not comply with 19.2.1 and 7/1/10. Example locations observed:
1. Wing A second through fourth floors
2. Wing C second through fourth floors
3. Wing D corridor adjacent to the Operating Room suite.

B. On 12/11/13 at 1:45pm a means of egress corridor was observed containing furniture which obstructed access to the operating hardware of a horizontal sliding cross corridor door which does not comply with 19.2.1 and 7.1.10. Location observed:

1. Wing D, first floor, Corridor 1D200 Won-style door leading to the Atrium.



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C. On 12/11/13 at 11:15 AM, an observation determined that in " C " wing, Basement, Serving Area OC093 adjacent to the Kitchen contained (2) sliding wire gates that are locked in the closed position after 10:00 PM each day and not unlocked until the next morning. An observation noted that an exit sign was placed at each of the gate locations. An interview with the Dietary Manager and an observation determined that within the kitchen a door to the serving line space was installed with an exit sign indicating that this was a path to an emergency exit. If individuals were to use the kitchen emergency egress door leading to the gated serving area they would become trapped and unable to exit this space which does not comply with 19.2.2.2.4.

A. Based on direct observation the morning of 12/10/13 while in the company of the manager of facilities operations, the chief engineer and the lead electrician, the surveyor finds that the Medical Gas Storage room (0A043) contains cylinder storage in excess 3000 cubic feet is naturally vented to the outside however the door from Mechanical Room (0A042) was blocked in the open position not providing the separation required by NFPA 99, 1999, 4-3.1.1.2.

1. A Wing Basement:

A. Due to 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.

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.

Based on observations during the survey walk-through, the facility failed to store flammable and combustible liquids in accordance with 19.3.2.1 and NFPA 99 1999 10-7.2.1. This deficiency could affect all staff members using the surrounding laboratory in the event of a spill or fire.

Findings include:

A. At 11:23 AM on 12/11/13 Wing C, Basement, Laboratory Storeroom 0C134 bottles of toxic chemicals were observed stored within their required cabinets, however, the waste Xylene and Achohol bottles were stored on their sides laying on top of bottles within already filled shelves which does not comply with 19.3.2.1, NFPA 99 1999 Ed. 10-7.2.1.

A. Based on direct observation the morning of 12/10/13 while in the company of the manager of facilities operations, the chief engineer and the lead electrician the surveyor finds that the identified emergency electrical panels are not identified as life safety, critical or equipment and the they contain a mixture of circuits all three branches of the essential electrical system in non compliance with NFPA 70, 1999, 517-32, 33 & 34, NFPA 99, 1999, 3-4.2.2.2 & 4-4.2.2.3. This condition exists throughout the A Wing on all floors.


1. Wing A, 4th floor:

A. Based on direct observation and staff interview the morning of 12/11/13 while in the company of the manager of facilities operations, the chief engineer and the lead electrician the surveyor finds while at the Med Gas Manifold Room 1E099 it could not be identified that the metal pipe systems connected to the manifolds are bonded as required by NFPA 70 1999 250-2(c).


1. Wing E, 1st Floor :

A. Based on direct observation the morning of 12/12/13 while in the company of the manager of facilities operations & the chief engineer, the surveyor finds that Elevator Recall is provided for Elevators C1, C2, and separate recall is provided for C3, C4. Elevators C1 & C2 are not installed in the same shaft as Elevators C3 & C4. These four elevators are not separated at the penthouse machine room therefore joining the two shafts. Further, C1 & C2 and C3 & C4 Elevators Lobbies are not separated on all floors. During fire alarm testing it was noted that C1 & C2 recall when their dedicated smoke detectors are activated, however C3 & C4 do not. C3 & C4 recall when their dedicated smoke detectors are activated however C1 & C2 do not. These four elevators share the same shaft by way of machine room and lobbies and must recall together as required by ANSI A17.3.

1. Wing C.