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Based upon observation, doors are equipped with locking hardware which can prevent access to required egress paths. This deficient practice could affect patients, staff, and visitors in the building because egress from the building could be impeded if improper locking devices are installed.

Findings include:

A. On February 13, 2018 at 1:50 PM while in the company of the CE & C, it was observed on the Fifth Floor West Wing that magnetic locking devices were installed at the stair exit doors for the Med/Surg Unit are not permanently disabled and thus can be secured in a manner which does not comply with 19.2.2.2.5.2.

B. On February 13, 2018 at 2:50 PM while in the company of the CE & C, it was observed that on the Third Floor West Wing center corridor intersection area that a Utility Closet door was equipped with a dead bolt lock operable only with a key from either side, which does not comply with 19.2.2.2.4 because the door can be secured against egress.

Based upon observation, typical cross corridor smoke barrier doors are equipped with astragals and coordinators which do not function to permit doors to close in proper sequence to a fully closed position. This deficient practice could affect patients, staff, and visitors in the building because smoke could pass between adjacent smoke compartments if the doors are not properly installed and maintained.

Findings include:

On February 13, 2018 at 12:55 PM while in the company of the CE & C it was observed on the Seventh Floor of the West Wing that cross corridor 2-hour Chicago vestibule doors are equipped with astragals and coordinators that do not function by not permitting the doors to always close in the correct sequence. This does not comply with Table 8.3.4.2. 8.3.3.3, and NFPA 80 2010 6.1.3. This condition was observed throughout the facility causing a pattern. The facility will need to review all the single swing pairs of cross corridor smoke barrier and building wing separation doors on all levels.

Based upon observation, stairways are not constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their ability to exit the building may be impeded if the stairways are not properly constructed and maintained.

Findings include:

A. On February 13, 2018 at 1:05 PM it was observed while in the company of the CE & C that Stair #5 was marked as an exit on multiple floors and had an elevator opening directly into the stair enclosure in noncompliance with 9.4.7. This stair does not comply as a required exit stair for any floor level.

1. Exit signage to define alternate routes to eliminate a dead end corridor condition was not provided as required by 7.10.1.1.

B. On February 14, 2018 at 9:00 AM while in the company of the CE & C it was observed that Stair #6 had a duct penetration at the Ground Floor Level that was not provided with a fire damper to comply with 7.1.3.2.1(10)(h).

C. On February 14, 2018 at 9:05 AM while in the company of the CE & C it was observed that stair identification signage at Stair #6 on the Main Floor Level (MFL) was not accurate as required by 7.2.2.5.4.1. The "Exit floor location-Main floor" with an arrow did not indicate the actual location of the exit at the Ground floor level and the arrow orientation did not direct occupants correctly.

1. A similar condition of inaccurate exit floor location and directional arrows, which do not comply with 7.2.2.5.4.1, was observed at the Sub-Basement Level of the Stair #4 accessing the lower old Boiler room level.

Based on observation, not all designated fire barriers are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors on the building because fire could pass between adjacent fire compartments if horizontal exits or fire barriers are not properly constructed.

Findings include:

On February 14, 2018, while accompanied by the DSS, observation determined that doors in designated 2 hour fire barriers are not self-closing as required by Table 8.3.4.2 and NFPA 80 2010 6.4.1.1.

Locations observed include:

1. 10:28 AM: Ground Floor pair of fire rated doors between the East Wing and the West Wing, because the door coordinator did not function properly.

2. 10:56 AM: North Center Wing Main Floor access panel, in Corridor west of designated Exit Passageway, because no spring is provided for the access panel.

Based upon observation, not all areas of the building are provided access to at least two means of egress as required. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building under emergency conditions could be impeded if remote exits are not provided.

Findings include:

A. On February 13, 2018 at 2:45 PM while in the company of the CE & C, it was observed that the Third Floor West Corridor leading from the Behavioral Health Unit to Stair #4, which also served as one of the exit accesses from the upper Boiler Room, had only one means of egress because the door at the Behavioral Health Unit was locked to prevent movement into the unit from the non-Behavioral Health unit side. This condition does not comply with 19.2.5.4.

B. On February 13, 2018 at 2:50 PM while in the company of the CE & C it was observed that the Third Floor West Corridor lacked exit signage to identify two exit paths from the section of the corridor containing the Patient Laundry room to comply with 7.10.1.5.1.

C. On February 13, 2018 at 3:10 PM while in the company of the CE & C it was observed that the old Boiler Room Mezzanine Level lacked visible exit signage to direct occupants to available exits required by 7.10.1.5.1.

D. On February 14, 2018 at 9:10 AM while in the company of the CE & C, it was observed that the Main Level West Lobby was not provided with exit signage to identify two means of egress when the Executive Office area is locked after hours. Although exit signage is visible at the stair inside the Executive Office area, access is not available after hours to comply with 39.2.5.3.1.


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While accompanied by the DSS, observation determined that corridors lack at least two remote exits required by 19.2.5.4.

Locations observed include:

E. February 13, 2018 at 2:20 PM: The southeast door from the East Wing Elevator Lobby (toward Exit Stair 1) lacks an exit sign above the door; the Elevator Lobby is thus provided with a single means of egress.

1. The cited door was also observed to be capable of being secured against egress as prohibited by 7.2.1.5.1.

2. The cited door was also observed to be equipped with a sign which reads "NO EXIT" as prohibited by 7.10.1.2.1.

F. February 14, 2018 at 8:50 AM: The northeast door from the East Wing Elevator Lobby (toward the Radiology Department) lacks an exit sign above the door; the Elevator Lobby is thus provided with a single means of egress.

Based on observation, not all vertical openings in the building are protected as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass between building stories if vertical openings are not protected.

Findings include:

A. On February 13 & 14, 2018 while in the company of the CE & C it was observed that vertical openings between floors are not sealed or protected to comply with 19.3.1.1.

Locations and conditions are as follows:

1. On February 13, 2018 at 12:30 PM at the Eighth Floor Elevator #5 Mechanical Room a floor hatch was not sealed to form an effective barrier against fire and smoke.

2. On February 13, 2018 at 1:20 PM at the Sixth Floor Electrical Room accessed from Stair #5, the old dumbwaiter now used as a utility shaft was not sealed to form an effective barrier against fire and smoke.

3. On February 13, 2018 at 2:05 PM at the Fourth Floor Electrical Room accessed from Stair #5, the old dumbwaiter now used as a utility shaft was not sealed to form an effective barrier against fire and smoke. Only the sheet metal slide door was provided.

4. On February 14, 2018 at 9:15 AM at the Main Floor Level the small closet near Stair #5 contained pipes through the floor which were not sealed to form an effective barrier against fire and smoke.


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B. On February 13, 2018, while accompanied by the DSS, observation determined that exit stairs exist at which intermediate rails at guardrails permit a sphere larger than 4 inches in diameter to pass as prohibited by 7.2.2.4.5.3.

Locations observed include:

1. 12:26 PM: Exit Stair 2.

2. 12:43 PM: Exit Stair 3.

Based upon observation, hazardous areas are not protected as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if they are not properly constructed.

Findings include:

A. On February 14, 2018 while in the company of the CE & C, it was observed that Hazardous areas are not enclosed in accordance with 19.3.2.1, 39.3.2.1, & 8.7.

Locations observed include:

1. At 8:50 AM it was observed that the Main Floor Executive Office corridor, Storage closets 1 & 2 filled with paper products did not have self-closing doors to comply with 8.7.1.2 and 8.4.3.5.

2. At 9:35 AM it was observed that the Main Floor Business Office Storage Room door, which had a 3-hour rating, was not not self-closing to comply with 8.7.1.2 and 8.4.3.5.

3. At 10:00 AM it was observed that the Storage Room near Stair #2 & the ER Office area was accessed through a 2-hour rated wall provided with a rated access door which was not self-closing to comply with 8.3.4.2 and NFPA 80 2010 6.4.1.1. This access door lacked a functional latching system when observed and was not provided with a means of releasing the latching system from inside the room if closed.

4. At 10:30 AM it was observed that the Kitchen Storage Room (containing soda supplies & other combustibles) was not provided with a self-closing door to comply with 8.7.1.2 and 8.4.3.5.

5. At 10:40 AM it was observed that the Alcohol Storage Room accessed through the Sump Pump room did not have a self-closing door to comply with 8.7.1.2 and 8.4.3.5.

6. At 10:25 AM while in the company of the CE & C it was observed that the Ground Level Hydraulic Elevator Machine Room lacked complete enclosure due to a transfer grille in the corridor wall which does not comply with 39.3.2.1, 8.7.1.2 and 8.4.3.5.

7. At 10:45 AM it was observed that the EVS Laundry Room corridor door contained a louver. The laundry Room is deemed a hazardous area due to combustible storage and soiled linen/mop collection containers exceeding 64 gal. capacity. The room is not enclosed to comply with 39.3.2.1, 8.7.1.2 and 8.4.3.5.

8. At 11:00 AM it was observed that the Biohazard Storage Room adjacent the Ramp Room at the access to the dumpster was provided with a transfer grill which exposes the means of egress to the effects of a fire condition originating in the Biohazard room. Separation from the Biohazard room is not provided to comply with 39.3.2.1, 8.7.1.2 and 8.4.3.5.


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B. On February 13, 2018, while accompanied by the DSS, observation determined that hazardous areas exist at which the doors in the enclosure walls are not self-closing as required by 19.3.2.1.3, Table 8.3.4.2, and NFPA 80 2010 6.4.1.1.

Locations observed include:

1. 1:20 PM: Seventh Floor East Wing Surgical Department Storage Room, south side of Corridor.

2. 1:21 PM: Seventh Floor East Wing Surgical Department Storage Room, south side of Corridor (immediately west of Storage Room cited above).

C. On February 13, 2018 at 1:22 PM, while accompanied by the DSS, observation determined that the door to the Seventh Floor East Wing former GI Room (West Operating Room, now used for storage) is not positive latching as required by 19.3.2.1.3, Table 8.3.4.2, and NFPA 80 2010 6.1.4.

Based on observation, cooking facilities are not constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the Kitchen to the remainder of the building if the equipment is not properly installed.

Finding include:

On February 14, 2018 at 10:35 AM while in the company of the CE & C, it was observed that the Kitchen deep fat fryer was stationed directly adjacent the open flame stove without minimum 18" separation or a separating baffle to comply with NFPA 96 2011 12.1.2.4.

Based on observation, not all portions of the building's fire alarm system are installed as required. This deficient practice could affect patients, staff, and visitors in the building because they could be unaware of a fire condition if the fire alarm system is not properly installed.

Findings include:

On February 14, 2018, while accompanied by the DSS, observation determined that fire alarm manual pull stations are located more than 48 inches above the floor as prohibited by NFPA 72 2010 17.14.4.

Locations observed include:

1. 8:58 AM: Third Floor east door to Exit Stair 2.

2. 8:59 AM: Third Floor south door to Exit Stair 2.

3. 9:00 AM: Third Floor door to Exit Stair 1.

Based on observation, the facility failed to provide a complete automatic sprinkler system where installed. This deficient practice could affect patients, staff, and visitors in the building because the automatic sprinkler system may fail to extinguish a fire if it is not properly installed.

Findings include:

A. On February 13, 2018 at 12:30 PM while in the company of the CE & C it was observed that the Elevator Penthouses are not provided with sprinkler heads at the sprinkler piping to comply with NFPA 13 2010 8.1.1(1).

B. On February 13, 2018 at 2:05 PM while in the company of the CE & C it was observed that the small closet on the Fourth Floor in the Electrical Room adjacent Stair/Elevator #5 was not provided with sprinkler protection to comply with NFPA 13 2010 8.1.1(1).

C. On February 14, 2018 at 8:45 AM while in the company of the CE & C it was observed that the Main Entry vestibule was not provided with sprinkler protection to comply with NFPA 13 2010 8.1.1(1).

D. On February 14, 2018 at 9:25 AM while in the company of the CE & C it was observed that the Materials Management Storage Room lacked a complete ceiling at the soffit adjacent the wall due to holes being made. The holes compromise the effectiveness of the sprinkler system by delaying activation when the above ceiling cavity is open to the room in a manner prohibited by NFPA 13 2010 8.6.4.1.1.

E. On February 14, 2018 at 10:25 AM while in the company of the CE & C it was observed that the Ground Floor Level Hydraulic Elevator Machine Room lacked sprinkler protection required by NFPA 13 2010 8.1.1(1).


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F. While accompanied by the DSS, observation determined that rooms or spaces are not covered by the automatic sprinkler system as required by NFPA 13 2010 8.1.1(1).

Locations observed include:

1. On February 13, 2018:

a. 12:34 PM: Ninth Floor Elevator Penthouse immediately west of Exit Stair 2.

b. 12:45 PM: Ninth Floor Elevator Penthouse immediately west of Exit Stair 3.

2. On February 14, 2018 at 8:55 AM: Third Floor East Wing Radiology Department Electrical Room near Nuclear Medicine.

Based on observation during the survey walk-through and document review, the facility failed to install and maintain its ventilation system in the required manner. This deficient practice could affect patients, staff, and visitors in the hospital because smoke and fire could be permitted to move between building stories and fire compartments if the system is not properly installed

Findings include:

A. On February 13, 2018 at 12:47 PM, while accompanied by the DSS, observation determined that a duct which penetrates the 2 hour fire rated wall assembly at the west side of the East Wing Eighth Floor Elevator Lobby lacks a fire damper required by NFPA 2012 5.3.1.1.

B. On February 13, 2018 at 12:32 PM, while accompanied by the DSS, observation determined that a duct which penetrates the fire rated floor assembly at the East Wing Ninth Floor Mechanical Room (serving Air Handling Unit S-10) is not provided with fire dampers required by 19.3.1.1 and NFPA 90A 2012 5.3.2.1.

C. On February 14, 2018 at 1:54 PM, while accompanied by the DSS, document review determined that deficiencies identified during the most recent fire/smoke damper inspection, conducted as required by NFPA 80 2010 19.4.1.1, have not been corrected as required by NFPA 80 2010 19.4.9. The most recent fire/smoke damper inspection report, prepared by an outside vendor and dated April 12, 2017, indicated that 8.97 percent of the dampers failed the inspection and that 29.15 percent of the dampers are inaccessible.

Based on document review and staff interview, the facility failed to conduct periodic fire drills as required. This deficient practice could affect patients, staff, and visitors in the hospital because the hospital staff may not be properly prepared for a fire emergency if fire drills are not conducted properly.

Findings include:

On February 14, 2018 at 12:50 PM, while accompanied by the DSS, document review determined that Third Shift fire drills do not include the transmission of a fire alarm signal as required by 19.7.1.4. Third Shift fire drills for which no fire alarm signal was transmitted include:
1. March 13, 2017.

2. June 28, 2017.

3. July 31, 2017.

4. November 30, 2017.

5. January 23, 2018.

Based on document review, not all fire door and other required door assemblies are periodically inspected and tested. This deficient practice could affect patients, staff, and visitors in the building because the doors could fail to operate properly under emergency conditions, thus either impeding egress or permitting fire and smoke to pass between fire or smoke compartments if the doors are not properly maintained.

Findings include:

On February 14, 2018 at 2:00 PM, while accompanied by the DSS, document review determined that the inspection of fire door and other required door assemblies is not documented as required by NFPA 80 2010 5.2.1.

Based on observation, not all portions of the electrical system are not constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical systems could fail to operate properly when needed if they are not properly installed

Findings include:

A. On February 13, 2018 at 2:30 PM while in the company of the CE & C, it was observed that a switch cover plate was missing at the Third Floor West Wing Patient belongings storage room in non-compliance with NFPA 70 2011 314.28(C).

B. On February 13, 2018 at 2:50 PM while in the company of the CE & C, it was observed that a receptacle adjacent to the sink at the Third Floor West Wing Patient Laundry was not provided with ground fault circuit interruption to comply with NFPA 99 2012 6.3.2.5 and NFPA 70 2011 210.8(B)(6).