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Based upon observation, contiguous non-healthcare occupancies are not properly separated from the Healthcare occupancy. Failure to provide proper separationjs can expose the Healthcare occupancy to the effects of fire and smoke.

Findings include:

On 12/8/21 at 11:55am while in the company of the MM it was observed thast the 1st floor east doors of the 1961 building accessing the adjacent Business occupancy building did not self-close to a latched condition to comply with NFPA 80 and 8.3.4.

Based upon observation, non-combustible construction is not maintained in the building identified as Type 1 (332) construction type. Failure to provide non-combustible construction can result in combustible fuel load contributing to fire severity and lack of control of a fire condition.

Findings include:

A. On 12/8/21 at 10:30am while in the company of the MM it was observed that a wood paneling enclosure was constructed in the 4th floor Mechanical room to provide privacy screening for a toilet fixture. The wood panel construction does not comply with 19.1.6.4 and 19.3.3.

B. On 12/8/21 at 10:30am while in the company of the MM it was observed that a wood plank platform was installed at the 4th floor Mechanical room shaft extending to the 5th floor level. The wood construction does not comply with 19.1.6.4.

Egress doors are not in full compliance with Code requirements. Failure to maintain doors in compliance can impede occupants' access to exits.

Findings include:

A. On 12/7/21 at 1:46pm while in the company of the MM it was observed that the cross corridor doors at the west entrance to the 5th floor OB unit is equipped with a magnetic lock system controlled by card readers. The door is marked as an exit access but is arranged so as not to be opened without card credentials. The installation does not comply with the requirements of 19.2.2.2.4 or 19.2.2.2.5.2. Surveyor notes that the locks were not currently active at the time of inspection but could not be determined to be permanently disabled to prevent reactivation of a non-compliant locking system.

B. On 12/8/21 at 11:00am while in the company of the MM it was observed that the ER suite lacked identification of a second exit to comply with 19.2.5.7.3.2(A). Exit signage directed all exit paths to a single corridor door. The 2nd exit indicated on the Life Safety Plans accessing the exterior through the stair was not maintained with exit signs and clearances for the movement of stretchers through this exit access. This exit door was equipped with compliant locking hardware.

C. On 12/8/21 at 11:05am while in the company of the MM it was observed that the corridor exit access door from the ER suite was equipped with Delayed Egress locking hardware but lacked the required signage to comply with 19.2.2.2.4(2) and 7.2.1.6.1.1(4).

Based upon observation, Exit stair enclosures are not maintained to provide a separated protected path of egress from the building. Failure to provide a protected path of egress can compromise the safety of occupants seeking refuge from a fire/smoke event.

Findings include:

On 12/7/21 at 2:25pm while in the company of the P it was observed that the 3rd floor east stair door near room 369 failed to self-close and latch to comply with 7.2.2.5.1.1, 7.1.3.2.1 and 8.3.4.

Suite separations are not maintained in accordance with Code requirements: Failure to maintain separations for the intent of fire & smoke compartmentalization can compromise the safety of occupants and their access to areas of refuge.

Findings include:

A. On 12/8/21 at 11:00am while in the company of the MM it was observed that the suite boundary (as defined by the available Life Safety Reference Plans) at the ER suite reception window was not resistant to the passage of smoke to comply with 19.2.5.7.1.2.

B. On 12/7/21 at 2:30pm while in the company of the MM it was observed that the 5th floor corridor is directed through a door at the surgery waiting room which does not swing in the direction of travel when egressing from the elevator lobby corridor to access the southwest stair to comply with 7.2.1.4.2.

During document review the facility could not provide testing of the battery lighting systems. Failure of testing may affect patient, visitors and staff during a utility outage.

The finding is:

On 12/8/21 at 1:30pm in the company of the BE, documents could not be provided for the monthly and annual testing of the facilities battery-operated lighting (operating room/egress/exit). NFPA 99, 2012, 6.3.2.211.5/NFPA 101, 2012, 7.9.3.1.2

Exit signs are not maintained in accordance with Code requirements. Failure to maintain exit signs to identify available egress routes can impede the movement of occupants and compromise the prompt evacuation of areas exposed to fire and smoke.

Findings include:

A. Exit and emergency lighting is not maintained by periodic inspection:

1. On 12/7/21 at 10:30am while in the company of the BE it was indicated that a record of monthly inspections for Exit signs and emergency lighting was not available for review to comply with 7.10.9.1.

2. On 12/8/21 at the following times and locations, while in the company of the MM or P, internally illuminated exit signs were observed not to be internally illuminated to comply with 7.10.5.2.

a. At 9:35am at the 4th floor west cross-corridor doors of the 1961 building.

b. At 9:42am at the 2nd floor at the stair across from room 256.

c. At 10:05am at the south door of the 4th floor sprinklered Mechanical Exhoust Fan room.

d. At 10:25am at the 4th floor entrance to the west middle stair of the 1973 building.

e. At 10:35am at the 4th floor entrance to the north stair in the non-sprinklered Mechanical room.

f. At 11:54am at the Basement level back exit stair from the Mechanical room.

Based upon observation, hazardous areas are not separated in accordance with Code requirements. Failure to properly separate Hazardous Areas can result in the spread of fire & smoke conditions beyond the source of ignition location within the Hazardous Area.

Findings include:

A. While in the company of the MM or P it was observed that areas deemed to constitute a Hazardous Area due to storage of combustibles are not properly separated from other areas to comply with 19.3.2.1 and 8.7. Conditions observed include:

1. On 12/7/21 at 2:20pm in the company of the MM, the sprinklered 5th floor Surgery Dept. Clean Storage room and the Equipment Storage room are not provided with self-closing doors which close in less thab 30 seconds to comply with 7.2.1.9.2. The doors to these rooms were equipped with closers, but observed to take a minimum of 50 seconds to come to a closed position.

2. On 12/7/21 at 1:42pm while in the company of the P, it was observed that the 3rd floor door to the Environment services room failed to close and latch to comply with 19.3.2.1.

3. On 12/7/21 at 2:05pm while in the company of the P, it was observed that the 3rd floor patient room 322 was being used as a storage room and lacked a self-closing door to comply with 19.3.2.1.

4. On 12/8/21 at 10:05am while in the company of the MM it was observed that 3 of 3 fire rated doors in fire rated building walls at the 1973 building 4th floor sprinklered mechanical room were observed not to self-close to a fully closed position to comply with 19.3.2.1 and 8.3.4 (due to air pressure relatioinships).

5. On 12/8/21 at 10:08 while in the company of the P it was observed that the 2nd floor patient room 232 was being used as a storage room and lacked a self-closing door to comply with 19.3.2.1.

Based on observation the facility failed to maintain fire alarm smoke detector installation. This deficient practice could result in the delayed response and alarm during a fire event, which may affect patients, staff and visitors.

The finding is:

A. On 12/8/21 at 11:15am in the company of the BE it was observed in the basement IT Server Room, that ceiling tiles are missing and others removed for the relief air ducting for spot cooling units allowing products of combustion to bypass installed smoke detection.

B. On 12/8/21 at 9:44am while in the company of the P it was observed that smoke detection for door release was located more than 5' from the doors located at the smoke barrier near the room 255.

Based on observation the facility failed to maintain fire sprinkler installation.
This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

Findings include:

A. On 12/8/21 at 10:24am while in the company of the P it was observed at the 1st floor Emergency Dept. Triage room that the escutcheon ring for the sprinkler head was missing and not in compliance with NFPA 13-2010, 6.2.7.1 & NFPA 25-2011, 5.2.1.1.2(3).

B. The finding is at the below locations and date & times while in the company of the facility staff it was observed that multiple ceiling tile/panels were either missing or falling out of the ceiling grid allowing the installed pendant sprinkler heads to be more than 12 inches from the interstitial ceiling above. NFPA 13, 2010, 8.6.4.1

1. 2/8/21 at 11:57am in company of the MM, the 1st floor File Storage room at the NE corner of the 1961 building.


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2. 12/7/21 at 2:25pm in company of the BE, the 3rd floor communication closet next to number 4 Elevator.

3. 12/8/21 at 9:40am in company of the BE, the 2nd floor communication closet next to number 4 Elevator.

4. 12/8/21 at 10:45am in company of the BE, the 1st floor communication closet next to number 4 Elevator.

5. 12/8/21 at 11:11am in the company of the BE, the Basement level Data room.

Based upon observation, areas open to the corridor are not provided protective features to comply with Code requirements. Failure to provide protective features can delay the prompt response to a fire/smoke condition which can compromise the corridor as a means of egress to reach an area of safety.

Findings include:

A. On 12/8/21 at 11:45am while in the company of the MM it was observed that the sprinklered main lobby waiting area and the main lobby reception/admitting area are open to the corridor and are not provided with smoke detection to comply with 19.3.6.1(2)(b) and 19.3.6.1(1)(c). The camera provided at the waiting area only is deemed not to qualify as the direct observation required in lieu of smoke detection.

Corridor doors are not provided with positive latching hardware. Failure to provide positive latching hardware can prevent the door assembly from providing a barrier to fire and smoke migrating from one side of the door to the other during a fire/smoke event.

Findings include:

A. On 12/7/21 at 1:51pm while in the company of the P it was observed that the corridor door at the 3rd floor ante room serving rooms 307 & 309 failed to positive latch to comply with 19.3.6.3.5 and CMS requirements for positive latching hardware on corridor doors.

B. On 12/7/21 at 2:30pm while in the company of the MM it was observed that the Surgery Locker room corridor doors are not positive latching to comply with 19.3.6.3.5 and CMS requirements for positive latching hardware for corridor doors. (Surveyor notes that these doors are the only access to a corridor from the defined suites as required by 19.2.5.7.3.2(B)).

C. On 12/8/21 at 11:58am while in the company of the MM it was observed that the 1st floor Locker room 1317 and the adjacent Disaster Storage room (formerly a locker room) 1315 lack positive latching door hardware to comply with 19.3.6.3.5 and CMS requirements for positive latching hardware for corridor doors.

Based on observation the facility failed to install required elevator controls electrical disconnects. Failure to install a single means to disconnect as required could leave the elevator car without power for the services required. This deficient practice could affect patients, staff and visitors.

The finding is:

A. On 12/8/21 at 11:20am in the company of BE, it was observed that a disconnecting means is provided for the car lights, receptacles and ventilation for Elevators #1 thru #4 however a lockable means to secure these disconnects is not provided. NFPA 101, 2012, 19.5.3 / NFPA 70, 2011, 620.53

Base on observation and staff interview during document review the facility could not provide testing of the Elevator Fire Safety Features. Failure of testing may affect patient, visitors and staff during a fire event.

The finding is:

B. On 12/7/21 at 11:05am in the company of the BE, documents could not be provided for the monthly testing of the facilities elevators Firefighter's service and recall functions as required by ASME A17.1.\ NFPA 101, 2012, 9.4.6.2.

Based upon document review, fire drills are not being documented as required by the Code. Failure to conduct and document training fire drills can result in staff not knowing proper response to fire/smoke conditions.

Findings include:

A. On 12/7/21 at 11:00am while in the company of the BE it was discovered that fire drill response documentation was not available for review regarding the following time frames:

1. No 2nd shift drills were available for 1st, 2nd, & 4th quarters.

2. No 1st shift drills were available for 4th quarter.

Based upon document review: maintenance, inspection & testing of doors is not being performed and documented. Failure to conduct periodic door inspections can result in non-functional opening protections to needed to impede the spread of fire and smoke conditions.

Findings include:

On 12/7/21 at 11:15am while in the company of the BE & DF it was indicated that documentation for door inspections within the last year were not available to comply with NFPA 101-2012, 7.2.1.15.

Based on staff interview the facility lacks complete bonding of the and medical gas piping system. Failure to install and maintain this installation could result in the piping system to become electrically energized. This deficient practice could affect patients, staff and visitors.

The finding is:

On 12/8/21 at 12:05pm in the company of the BE, it could not be confirmed through observation and staff interview that electrical bonding of the facility's medical gas piping system has been completed. This is not in compliance with NFPA 70, 2011, 250.104 (B).

Based on observation the facility failed to secure compressed gas cylinders. This deficient practice could affect staff during maintenance activities.

The finding is:

On 12/8/21 at 12:00pm in the company of the BE in the medical gas manifold room it was observed that multiple nitrous oxide tanks were unrestrained or otherwise protected from tipping or falling. NFPA 99, 2012, 11.6.2.3(12).

GFCI receptacles are not provided where required adjacent wet locations. Failure to provide protective devices can result in electrical shock hazards to occupants using the system.

Findings include:

A. On 12/7/21 at 2:10pm while in the company of the MM it was observed at the substerile area between OR #1 & OR #2 that a critical power duplex receptacle within 6' of the sink fixture could not be confirmed to be GFCI protected to comply with NFPA 70-2011, 210.8(B)5.

B. On 12/7/21 at 1:43pm while in the company of the P it was observed in the toilet room across from room 305 that the electrical receptacles within 6' of the sink could not be confirmed to be GFCI protected to comply with NFPA 70-2011, 210.8(B)5.

C. On 12/8/21 at 11:30am while in the company of the MM it was observed that a 4-plex outlet in the 1st floor Lab room adjacent 1260 was located within 6' of a sink and lacked GFCI protection to comply with NFPA 70-2011, 210.8(B)5.

Electrical receptacles are not installed in accordance with Code requirements. Failure to install required receptacles can result in loss of electrical service required for critical equipment or life support.

Findings include:

A. On 12/7/21 between 2:10pm and 2:20pm while in the company of the MM it was observed that 6 of 6 ORs on the 5th floor lacked at least one receptacle served by the normal power system to comply with NFPA 70-2011, 517.19(A). Only critical branch emergency power was observed to be provided in the ORs believed to be on a single transfer switch of the emergency power system.

B. On 12/8/21 at 10:00am while in the company of the MM it was observed that a compressor, Data panel, computer outlet were located on a life safety branch panel serving life safety loads such as Exit signs and emergency lighting. The panel appeared to have mixed loads of Life Safety/Critical/Equipment in non-compliance with NFPA 99-2012, 6.4.2.2.

C. On 12/8/21 at 11:32am while in the company of the MM it was observed that the 1st floor Lab room 1260 was provided with plugmold receptacles at the east end of the room where two of the receptacles coverplates were red indicating circuiting from the emergency power system. The remainder of the receptacles in the plugmold system appeared to be ivory indicating circuiting from the normal power system. Mixture of the emergency power system and normal power system in the same raceway is not permitted as stated by NFPA 70-2011, 700.10(B) and NFPA 99-2012, 6.4.2.2.6.1.

During document review the facility could not provide testing of the Essential Electrical System. Failure of testing may affect patient, visitors and staff during a utility failure.

The findings are:

A. On 12/7/21 at 11:05am in the company of the BE, evidence of the following could not be provided.

1. Documents for the weekly inspection of the two facility emergency generators were not provided from July 2021 to present. NFPA 110, 2010, 8.4.1

2. Documents for the monthly operation of the two facility emergency generators under load were not provided from July 2021 to present. NFPA 110, 2010, 8.4.2

3. Documents for the annual load bank operation and testing for the two facility generators were not provided. The last documents for the annual load bank indicate completion in February 2020. NFPA 110, 2010, 8.4.2.3