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Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the means of egress in accordance with Life Safety Code 19.2 and 7.1.10.1.
This was evidenced by:
1.Storage Door 6604 is greater than 7" from wall when fully open. Only opens 90 degree. Needs to fully open.

The Maintenance Director acknowledged the means of egress deficiency during the tour of the facility.

This deficient practice could has the potential to affect all staff, visitors, and residents ' through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintained delayed exit doors in accordance with Life Safety Code Section 7.2.1.6.2 and 19.2.2.2.4 This was evidenced by the following:

1. 1st floor -Door 1665A did not release on water flow activation.
2. Door 7611G - nuisance alarm - Central Tower (Corrected during survey)
3. Door 7649F - nuisance alarm – Central Tower (Corrected during survey)
4. Door 1608a - nuisance alarm – Central Tower
5. "Alarm verification in progress" upon smoke detector activation door 7603b didn't close upon alarm. (Corrected during survey)
6. Door 7649F didn't release upon smoke detector activation. (Corrected during survey)

The Maintenance Director acknowledged the door deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing an excessive time to exit from the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintained egress doors in accordance with Life Safety Code Section 19.2.2.2.4 This was evidenced by the following:
1. All delayed egress doors are all equipped with nuisance alarms.

The Maintenance Director acknowledge door deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing the delay in exiting the smoke compartments.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintained egress doors in accordance with Life Safety Code Section 19.2.2.2.7 This was evidenced by the following:
1. 4th floor - Staff elevator lobby fire doors not latching. (Corrected during survey)
2. Fire door will not latch in solid utility A1343SU. 1st floor. (Corrected during survey)
The Maintenance Director acknowledge egress door deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing the spread of fire and smoke throughout the smoke compartments.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintained stairway doors in accordance with Life Safety Code Section 7.2.1.8.2 and 19.2.2.2.7. This was evidenced by the following:

1 .6th floor- Door 6S6307 rated as 20 min door instead of 45 min.
2. Central Tower 5th and 6th floor fire doors. (Corrected during survey)
3. Fire doors 65-8 6th floor near elevator not closing. (Corrected during survey)
4. Fire doors 5585 not self-closing. (Corrected during survey)

The Maintenance Director acknowledged the door deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation during the walk-through, the facility failed to maintain fire rated doors in accordance with Life Safety Code 19.2.2.2.7. This was evidenced by:
1. East Tower, 1st Floor fire door 1S1231 doesn't latch. (Corrected during survey)
2. East Tower -7th floor -Door to fire rated room 7N7136 not labeled as a rated door. (Corrected during survey)
3. East Tower - 6th floor- Door 6S6307 rated as 20 min door instead of 45 min. (Corrected during survey)

The maintenance director acknowledged the door discrepancies during the survey.

The deficiencies have the potential to affect all occupants, who might include staff, residents and visitors.

This deficiency was discussed with the Administrators and Maintenance Director during the exit conference conducted June 8, 2017.

Based on observation during the walk-through, the facility failed to maintain rated doors in accordance with Life Safety Code 19.2.2.2.7. This was evidenced by:
1. Smoke/Fire door does not latch 1426A. (Corrected during the survey)

The Maintenance Director acknowledged the door discrepancies during the survey.

The deficiency has the potential to affect all occupants, who might include staff, residents and visitors.

This deficiency was discussed with the Administrators and Maintenance Director during the exit conference conducted June 8, 2017.

Based on observation during the course of the survey conducted on June 5, 2017, it was determined the facility failed to maintain the stair enclosure in accordance with NFPA 101, 39.2.2.3, 7.2.2 and 7.1. The following evidenced this:

During the walk-through with the Maintenance Personnel;
A. Unable to verify fire-rating of stairway on 3rd floor, stair #3, UL label was painted over.

The deficiency has the potential to affect occupants, who might include staff, patients and visitors within 1 of 4 stair enclosures; item was discussed during the survey and again during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain smoke-proof enclosure. This was evidenced by:
1. Deteriorating drywall in 3501 near drain pipe (fire rated room) Central Tower 3rd floor. (Corrected during survey)

The Maintenance Director acknowledged the smoke-proof deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain a second means egress from a smoke compartment in accordance with Life Safety Code Section 19.2.5.2. This was evidenced by the following:
1. 4th and 5th floors contained construction plastic covering both sides of the smoke barrier door preventing a second means of egress from the smoke compartment creating a dead-end corridor. (Corrected immediately during survey)

The Maintenance Director acknowledged the 2nd means of egress deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing a excessive time to exit from the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain exit signs in accordance with Life Safety Code Section 19.2.10 This was evidenced by the following:
1. Room 0634 exit light out in North Tower basement. (Corrected during survey)
2. Exit sign was covered at 2nd exit from smoke compartment. (Corrected during survey)

The Maintenance Director acknowledged the exit signage deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain exit signs in accordance with Life Safety Code Section 19.2.2.2.7 This was evidenced by the following:
1. Remove exit sign above Ultrasound exam room 1. (Corrected during survey)
2. Need exit sign directing to public access from N basement exit to outdoor construction area. (Corrected during survey)

The Maintenance Director acknowledged the exit sign deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment adding confusion in exiting the smoke compartments.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation during the walk-through, the facility failed to maintain exit sign in accordance with Life Safety Code 19.2.10.1. This was evidenced by:
1. Room 0634 exit light out in North Tower basement.

The Maintenance Director acknowledged the exit sign deficiency during the walk through.

The deficiency has the potential to affect all occupants, who might include staff, residents and visitors
.
This deficiency was discussed with the Administrators and Maintenance Director during the exit conference conducted June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintained vertical openings in accordance with Life Safety Code Section 19.3.1 This was evidenced by the following:
1. Room 168A above ceiling penetration, Central Tower 1st floor.
2. Room 0541A above ceiling penetration, Central Tower 1st floor. (Corrected during survey)
3. Room 3590 ceiling penetration, Central Tower 3rd floor.
4. Room 4590 ceiling penetration.

The Maintenance Director acknowledged the exit signage deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation during the walk-through, the facility failed to maintain vertical openings in accordance with Life Safety Code 19.3.1.1. This was evidenced by:
1. Room 3589 ceiling penetration - North Tower. (Corrected during survey)
2. Room 4590 ceiling penetration – North Tower. (Corrected during survey)

The Maintenance Director acknowledged the exit sign deficiency during the walk through.

The deficiency has the potential to affect all occupants, who might include staff, residents and visitors.

This deficiency was discussed with the Administrators and Maintenance Director during the exit conference conducted June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain hazardous area doors in accordance with Life Safety Code Section 19.3.2.1. This was evidenced by the following:
1. Fire door will not latch in room soiled linen room BG224SL. Basement. (Corrected during survey)

The Maintenance Director acknowledge door discrepancy during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing fire or smoke to develop throughout the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation during the survey, conducted on June 5, 2017, it was determined the facility failed to install and maintain the fire alarm system in accordance with NFPA 101, section 39.3.4 and 9.6, including NFPA 72 National Fire Alarm Code. The following evidenced this:

During the walk through with the Maintenance Personnel;
A. Suite 315, smoke detectors are located within 3 feet of a return or supply diffuser which could prevent operation of the detector by rooms 315.04 and 315.11.

The fire alarm deficiency has the potential to affect all room occupants, who might include staff, patients and visitors within the suite; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with Life Safety Code 9.7.7 and NFPA 25 This was evidenced by the following:
1. Multiple exit delayed egress doors did not open upon activation of smoke detectors and water flow alarms.

The Maintenance Director acknowledged the fire alarm deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintained the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) 13 and Life Safety Code Section 19.3.5
This was evidenced by the following:
4th floor - Sprinkler heads closer than 6' to each other in room A4112

The Maintenance Director acknowledge sprinkler deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing fire to develop throughout the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, conducted on June 6, 2017, it was determined the facility failed to install the automatic fire sprinkler system in accordance with NFPA 101, section 19.3.5, 19.3.5.1, 9.7 including NFPA 25. The following evidenced this:

During the walk through with the maintenance personnel;
A. Storage is too high in clean linen closet. Maintain minimum clearance of 18 inches below all sprinkler deflectors, NFPA 25, section 5.2.1.2

The fire sprinkler deficiencies has the potential to affect all room occupants, who might include staff, patients and visitors; items were discussed during the survey and again during the exit conference.

Based on record review, observation and staff interview during the course of the survey conducted on June 5, 2017, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101, section 19.3.5.1, 9.7, 9.7.5. The following evidenced this:

During the walk-through of the facility with the Maintenance Personnel;
A. Suite 340 - Storage is too high in storage closet. Maintain minimum clearance of 18 inches below all sprinkler deflectors, NFPA 25, section 5.2.1.2. Storage was lowered during survey to allow 18 inches of clearance from sprinkler deflector.

The fire sprinkler deficiencies has the potential to affect all room occupants, who might include staff and visitors; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) 13 and Life Safety Code Section 19.3.5. This was evidenced by the following:
1. Cover plate missing on sprinkler in solid utility A2319SU. 2nd floor. (Corrected during survey)
2. 2nd floor - Missing escutcheon on sprinkler head near room A2120. (Corrected during survey)
3. 1st floor - Missing sprinkler escutcheon in room A2319SU. (Corrected during survey)
4. Missing data plate and feed location on pre-action system room A1343SU - 1st floor
5. Missing sprinkler escutcheon plate in room A1342
6. Cover plate missing on sprinkler in solid utility A2319SU. 2nd floor. (Corrected during survey)
7. Combustible storage is closer than 18" from sprinklers in room AG316.

The Maintenance Director acknowledge automatic sprinkler deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing fire to develop throughout the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation during the walk-through, the facility failed to maintain the fire sprinkler system in accordance with Life Safety Code 9.7.5 and NFPA 25. This was evidenced by:
1. Sprinkler escutcheon outside room 9 in parking area for patients. In the OR, First floor, North Tower.
2. Sprinkler escutcheon missing in registration closet. North Tower.
3. Room 0560 in North Tower basement has missing sprinkler escutcheon.
4. Sprinkler escutcheon plate not flush with ceiling tile (gap greater than 1/2") outside of room 0670. North Tower, basement.
5. Painted fire sprinkler trim plate in room 7626. North Tower.

The Maintenance Director acknowledged the discrepancies during the walk-through.

The deficiency has the potential to affect all occupants, who might include staff, residents and visitors.

This deficiency was discussed with the Administrators and Maintenance Director during the exit conference conducted June 8, 2017.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This was evidence by the following:
The facility failed to maintain the automatic sprinkler system:
1. Sprinkler escutcheons have 1/4+ gap in room 1N1110U and 1S1229U - East Tower. (Corrected during survey)

The maintenance director acknowledged the sprinkler deficiency during the survey.

The sprinkler deficiency has the potential to affect all occupants, who might include staff, residents and visitors.

This deficiency was discussed with the Administrators and Maintenance Director during the exit conference conducted June 8, 2017.

Based on observation and staff interview, it was determined that the facility failed to maintain a portable fire extinguisher as required by NFPA 10 Chapter 4. This was evidence by the following:

1. Fire extinguisher near room 3 had a pressure gauge that was below the
green safe level. (Corrected during the survey)

The Maintenance Director acknowledged this deficiency during the survey.

This deficiency could affect all visitors and stall in the event of fire.

This was discussed during the exit conference.

Based on observation during the walk-through, the facility failed to maintain portable fire extinguishers in accordance with Life Safety Code 19.3.6.1 and National Fire Protection Association (NFPA) 10.This was evidenced by:
1. Need ABC extinguisher on East Tower, 2nd floor in room 2N2018. (Corrected during survey)

The Maintenance Director acknowledged the portable fire extinguisher deficiency during the survey.

The fire extinguisher deficiency has the potential to affect all occupants, who might include staff, residents and visitors.

This deficiency was discussed with the Administrators and Maintenance Director during the exit conference conducted June 8, 2017.

Based on observation, staff interview and record review, it was determined that the facility failed to maintain a portable fire extinguisher as required by NFPA 10 Chapter 4. This was evidence by the following:
1. Fire extinguisher in the MRI Control room had an expired inspection tag.
(Corrected during the survey)

The Maintenance Director acknowledged this deficiency during the survey.

This deficiency may affect all occupants in the event of fire.

This deficiency was discussed with the Administrative staff and Maintenance Director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain automatic closing doors in accordance with Life Safety Code Section 19.3.6.3. This was evidenced by the following:
1. Automatic closing doors at locations 8601, 7600E, and 3620 do not positively latch closed. (Corrected during survey)

The Maintenance Director acknowledged the door deficiencies during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain smoke barriers in accordance with the Life Safety Code 19.3.7.3.
1. 3 penetrations above ceiling in room A2120. 2nd floor. (Corrected during survey)
2. Penetration above ceiling in solid utility A1343SU on SW wall. 1st floor. (Corrected during survey)
3. Penetration above ceiling on southeast wall with chilled and heated water piping in public elevator lobby. 1st floor. A1200. (Corrected during survey)
4. 1 penetration on south wall in biohazard room BG221. Basement. (Corrected during survey)

The Maintenance Director acknowledged the smoke barrier deficiencies during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing fire or smoke to develop throughout the smoke compartment.

These deficiencies were discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation during the survey, it was determined that the facility failed to maintained smoke barrier construction in accordance with Life Safety Code Sections 8.6.7.1 (1) and 19.3.7.3. This was evidenced by the following:
1. Wall penetration in room 7529 (Corrected during the survey)
2. Penetration through firewall above door 65-8, Open void across firewall rm. 6566. (Corrected during the survey)
3. Green flexible tube penetrates firewall in room 4539. (Corrected during the survey)
4. Rooms 4559, 4569, & 4570c do not go floor to ceiling. (Corrected during the survey)
5. Penetration around drain line 5539 (Corrected during the survey).
6. Penetration around flex tubing on north wall in room 3563. (Corrected during the survey)
7. Wall penetrations room 4663. (Corrected during the survey)
8. Wall penetration conduit of electrical room 3606. (Corrected during the survey)
9. No fire caulking around data lines above in room 3607. (Corrected during the survey)
10. Wall penetrations room 3620, 12. Fire caulking needed around sprinkler pipe in room 3660a and 2630. (Corrected during the survey)

The Maintenance Director acknowledged the smoke barrier deficiencies during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

All deficiencies were discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation during the walk-through, the facility failed to maintain the smoke barrier construction in accordance with Life Safety Code 19.3.7.3. This was evidenced by:
1. Penetration in 2S2306A, 4x4 hole with yellow conduit SW wall of East Tower.
2. Penetration in 2S2200U, North wall of East Tower
3. Penetration in NW wall near back-flow north mechanical room of East Tower. (Corrected during survey)
4. Fire caulking needed around sprinkler pipe in room 3660a. (Corrected during survey)
5. Fire caulking needed around sprinkler pipe in room 2630. (Corrected during survey)

The Maintenance Director acknowledged the smoke barrier construction deficiencies during the survey.

These smoke barrier construction deficiencies have the potential to affect all occupants, who might include staff, residents and visitors.

All deficiencies were discussed with the Administrators and Maintenance Director during the exit conference conducted June 8, 2017.

Based on observation and staff interview during the course of the survey conducted on June 5, 2017, it was determined the facility failed to maintain power strips and extension cords in accordance with NFPA 70, National Electric Code. The following evidenced this:

During the walk through of the facility with the Maintenance Personnel;
A. Suite 230 - Intake office contained a light duty power strip plugged into a light duty power strip with the potential to overload the circuit. Both power strips were rearranged and plugged directly into the wall outlet during the survey.

The electrical deficiency has the potential to affect all room occupants, who might include staff and visitors; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the electrical junction box in accordance with Life Safety Code Section 19.5.2.1 This was evidenced by the following:
1. Room A3325 - open lighting junction box. 3rd floor. (Corrected during survey)

The Maintenance Director acknowledged the electrical deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interviews during the survey, it was determined that the facility failed to maintained electrical openings in accordance with 19.5.1.1. This was evidenced by:
1. Open Junction box above room 4659, and room 3606.
(Corrected during survey)

The Maintenance Director acknowledged the electrical deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

The deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation during the walk-through, the facility failed to maintain the electrical system in accordance with Life Safety Code 19.5.1.1.This was evidenced by:
1. Open electrical junction boxes in rooms 7N7134, 2N2160U, 1S1229U north wall, East Tower, 6th floor. (All were corrected during survey)

The Maintenance Director acknowledged the electrical deficiencies during the survey.

These electrical junction box deficiencies have the potential to affect all occupants, who might include staff, residents and visitors.

All deficiencies were discussed with the Administrators and Maintenance Director during the exit conference conducted June 8, 2017.

Based on record review and staff interview during the survey, conducted June 5, 2017, it was determined the facility failed to conduct fire drills in accordance with NFPA 101, 21.7.1. The following evidenced this:

During review of the facility records with the Maintenance Personnel;
A. Simulated fire drills were conducted once per quarter, reports indicate there was no activation of any audible notification devices to alert staff in maintaining the awareness of the alarm signals. Audible signal are required for every fire drill performed.

The fire drill deficiency has the potential to affect all occupants, who might include staff, patients and visitors within 2 of 2 smoke compartments; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain electrical power cords in accordance with NFPA 99, and Life Safety Code Section 10.2.3.6. This was evidenced by the following:

1. Refrigerator is plugged into a power strip corridor near south mechanical room. (Corrected during survey)

The Maintenance Director acknowledged the electrical power cord deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

The deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain proper electrical practices in accordance with Life Safety Code Section 19.5.2.1 This was evidenced by the following:
1. 1st floor - Appliance plugged into power strip room A111. (Corrected during survey)
2. Basement - Appliance plugged into power strip room AG317. (Corrected during survey)

The Maintenance Director acknowledge the electrical deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by improper use of electrical equipment within the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.