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Based on observation, not all portions of the health care occupancy are separated from adjacent non-confirming occupancies. This deficient practice could affect any patients, staff, and visitors in the building because smoke and fire could pass from the non-conforming occupancy to the health care occupancy if the proper separation is not provided.

Findings include:

A. On July 25, 2017 at 1:30 PM while in the company of the LSC, it was observed that the 2-hour barrier at the 1st floor level Servery corridor door was not self-closing to comply with 19.1.3.4.1 and 8.3.3.1.

B. On July 25, 2017 at 2:00 PM while in the company of the LSC, it was observed that the 2-hour barrier door at the Ground floor level Tunnel 'A' separating the healthcare building from the Boiler House building was not self-closing to a latched condition to comply with 19.1.3.4.1 and 8.3.3.1 because the door rubs on the frame.

C. On July 25, 2017 at 11:40 AM while in the company of the LSC, it was observed that the 2-hour barrier wall on the 2nd floor level above the ceiling of the old administration area offices had penetrations that were not sealed to afford the required fire rating to comply with 19.1.3.4.1 and 8.3.5.1.


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D. On July 25, 2017 at 10:08 AM, while accompanied by the DEF, observation determined that the window in the designated 2 hour fire barrier at the Second Floor landing for the Glass Elevator Lobby does not carry a minimum 1-1/2 hour fire resistance rating as required by 19.1.3.5 and Table 8.3.4.2.

E. On July 25, 2017 at 1:47 PM, while accompanied by the DEF, observation determined that the designated 2 hour fire barrier at the Ground Floor Corridor immediately north of Exit Stair 007 does not form a complete barrier, as required by 19.1.3.5 and 8.3.1.2, because the 2 layers of drywall on each side of the existing metal studs have been removed from the lower portion of the wall (to a distance of 2 feet above the floor) due to water damage.

Based on observation, not all portions of the building constitute structures of complaint construction types. This deficient practice could affect patients, staff, and visitors in the building because fire conditions could cause the building structure to fail prematurely if a compliant construction type is not provided.

Findings include:

A. Structural components of the building were observed not to be provided with the required hourly rated protection identified for the Type I (332) construction type in accordance with 19.1.6.1.

Locations observed include:

1. On July 24, 2017 at 1:45 PM while in the company of the LSC, it was observed in the 8th floor north penthouse electrical switchgear room (accessed from the roof) that the steel beam supporting the the roof system was unprotected to achieve the 1.5-hour rating. The penthouse was not otherwise provided with sprinkler protection to permit compliance with 19.1.6.2.

2. On July 25, 2017 at 9:00 AM while in the company of the LSC, it was observed above the ceiling on the 7th floor near the cross corridor smoke barrier doors to the east wing that a steel beam supporting the floor above was unprotected not to achieve the 2-hour rating required.

3. On July 25, 2017 at 1:15 PM while in the company of the LSC & FE, it was observed above the ceiling at the 1st floor level old Cafeteria Servery that a steel column supporting the northwest corner of the 7-story west wing of the healthcare occupancy building above was unprotected not to achieve the 3-hour rating required.


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A. While accompanied by the DEF, observation determined that required fireproofing materials had been removed from structural steel components, which reduces the fire rating required for that steel below what is required by 19.1.6.2 and NFPA 220 2012 Table 4.1.1.

Locations observed include:

1. July 24, 2017, at 2:44 PM: Seventh Floor, steel beam above ceiling on south side of smoke barrier between Smoke Compartments 7C and 7D.

2. July 25, 2017, at 8:47 AM: Sixth Floor, steel beam above ceiling directly directly south of cross-corridor doors north of Elevators 4 and 5.

Based on observation, means of egress doors are not maintained free of impediments to access areas of refuge or exits from the building. This deficient practice could affect any patients, staff, and visitors in the building because the failure to provide an unobstructed means of egress can compromise occupants' ability to promptly reach an area of safety if egress doors are not maintained free of impediments.

Findings include:

A. On July 25, 2017 at 10:25 AM while in the company of the LSC, it was observed on the 3rd floor Adolescent unit that the Kitchen/Pantry corridor door was equipped with both a latching device and a dead bolt lock operated by key only which could require two releasing operations to open the door when both are engaged which does not comply with 7.2.1.5.10.2.

B. On July 25, 2017 at 1:35 PM while in the company of the LSC, it was observed on the 1st floor level at the north end of the north-south corridor in the healthcare building that the cross corridor aluminum/glass door providing access to and designated egress from the cafeteria area was locked with a key-only dead bolt lock which does not comply with 7.2.1.5.10.2.

Based on observation, not all egress doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress under emergency conditions could be impeded if they are not properly installed and maintained

Findings include:

A. On July 25, 2017, while accompanied by the DEF, observation determined that doors in egress paths, at which no patient special needs exist for specialized protective measures, are secured against egress as prohibited by 19.2.2.2.5.1. Locations observed include:

1. 9:05 AM: Fourth Floor pair of doors from the Glass Elevator Lobby to the Corridor to the east.

2. 9:39 AM: Third Floor pair of doors from the Glass Elevator Lobby to the Corridor to the east.

B. On July 25, 2017 at 11:45 AM, while accompanied by the DEF, observation determined that the Ground Floor door to Exit Stair 006 does not swing in the direction of egress as required by 7.2.1.4(2).

Based on observation, not all stairways are constructed as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if stairways are not properly constructed.

Findings include:

On July 24, 2017 at 2:04 PM, while accompanied by the DEF, observation determined that directional signage within exit stair enclosures does not comply with 7.2.2.5.4 for the reasons stated below. This condition was observed at all exit stair enclosures throughout the building which are over five stories in height. The conditions which do not comply with 7.2.2.5.4 include:

A. The directional signage does not include Braille characters to comply with ICC/ANSI A117.1, in accordance with 7.10.8.2, as required by 7.2.2.5.4.1(G).

B. The indication of the floor level is not provided on the directional signage using tactile symbols as required by 7.2.2.5.4.1(H).

C. The stairway identification is not located at the top of the directional signage in minimum 1 inch tall characters as required by 7.2.2.5.4.1(J).

D. The directional signage lacks signage which reads "NO ROOF ACCESS" in minimum 1 inch tall characters as required by 7.2.2.5.4.1(K).

E. The floor level is not identified in the middle of the directional signage in minimum 5 inch tall characters as required by 7.2.2.5.4.1(L).

F. The upper and lower terminus is not identified on the bottom of the directional signage in minimum 1 inch tall characters as required by 7.2.2.5.4.1(M).

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the normal power supply. This deficient practice could affect any patients, staff, and visitors in the building because the failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way if the necessary illumination is not present.

Findings include:

On July 25, 2017 at 1:45 PM while in the company of the LSC, it was observed that typical exit discharge lighting (as observed at the exterior exit discharge for the northeast stair) was not of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 7.9.1.3.

Based on observation, not all emergency lighting in the building is installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their ability to exit the building under emergency conditions could be impeded if emergency lighting is not properly provided.

Findings include:

On July 25, 2017 at 1:35 PM, while accompanied by the DEF, observation determined that emergency lighting is not provided, as required by 7.9.1.2, from First Floor exterior exit door for Exit Stair 007 to the southwest exterior corner of the building (the area between the hospital and the non-conforming structure).

Based on observation, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

A. On July 25, 2017 at 9:45 AM while in the company of the LSC, it was observed on the 4th floor level that the south side of the smoke barrier doors between smoke compartments 4B & 4C that exit signage was not provided to identify the required second exit from the corridor when the doors are closed to comply with 19.2.5.4 and 7.10.1.5.

B. On July 25, 2017 at 10:20 AM while in the company of the LSC, it was observed on the 3rd floor level that the 6-bed Child unit corridor door lacked exit signage to identify the required second exit from the corridor when the door is closed to comply with 19.2.5.4 and 7.10.1.5.

C. On July 25, 2017 at 10:25 AM while in the company of the LSC, it was observed on the 3rd floor level at the south end of the Adolescent unit corridor that the exit sign was not placed at the door intended to provide access to the second exit from the corridor to comply with 19.2.5.4 and 7.10.1.5.

D. On July 25, 2017 at 2:00 PM while in the company of the LSC, it was observed on the Ground floor level that the old materials management area lacked exit signage to define available exit access from the area to comply with 19.2.5.5.2 and 7.10.1.5.


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E. On July 24, 2017 at 2:46 PM, while accompanied by the DEF, observation determined that the Seventh Floor egress path, toward the north through the cross-corridor doors in the designated smoke barrier between Smoke Compartments 7B and 7C, is not identified by an exit sign as required by 7.10.1.1.

F. On July 25, 2017, while accompanied by the DEF, observation determined that doors which may be mistaken for egress doors are not labeled "NO EXIT" as required by 7.10.8.3.1. Locations observed include:

1. 11:41 AM: Ground Floor door to the Southwest Laboratory Convenience Stair.

2. 11:44 AM: Ground Floor door to the Southeast Laboratory Convenience Stair.

G. On July 25, 2017 at 10:36 AM, while accompanied by the DEF, observation determined that an exit sign, at the Second Floor Corridor to the non-conforming structure, above the pair of doors in the designated 2 hour fire barrier, identifies an incorrect exit path as prohibited by 7.10.1.1.

Based on observation, not all vertical openings in the building are protected as required. This deficient practice could affect any 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 July 24, 2017 at 1:50 PM while in the company of the LSC, it was observed on the 8th floor penthouse level that not all ducts which leave the penthouse level through the floor or into shaft enclosures are protected with fire dampers in accordance with 19.3.1 and 8.3.5.7. Fire dampers were observed at other ducts through the floor, but those labeled as "general supply" ducts to the west did not have access doors to verify the existence of fire dampers at the floor. Those to the east labeled as "nursery exhaust" ducts did not have fire dampers where they appeared to enter a shaft enclosure. Upon later review from the 6th floor level on 7/25/17 at 8:55am it was observed that these ducts appeared to communicate to a shaft open to the above ceiling space of the 6th floor level. The shaft enclosure connecting the 6th thru 8th floor levels was incomplete.

B. On July 25, 2017 at 9:10 AM while in the company of the LSC, it was observed on the 6th floor in the main elevator lobby area that floor penetrations/abandoned pipe penetrations were not sealed in accordance with tested design assemblies to comply with 19.3.1 and 8.3.5.1.

C. On July 25, 2017 at 9:55 AM while in the company of the LSC, it was observed on the 4th floor at the west stair (003) that a duct passed through the stair. Fire dampers at both wall penetrations in accordance with 7.1.3.2.1(10)h could not be observed due to access door location.

D. On July 25, 2017 at 10:15 AM while in the company of the LSC, it was observed on the 3rd floor at the west stair (003) that wall penetrations above the door were not sealed to comply with 8.3.5.1 and 7.1.3.2.1.

E. On July 25, 2017 at 11:10 AM while in the company of the LSC, it was observed on the 2nd floor near the cross corridor pair of doors to the east wing (old same day surgery area) that a shaft, adjacent the out-of-service elevator, connecting floor levels was not constructed as a fire rated enclosure to comply with 19.3.1 and 8.6.5. Voids at the enclosure walls existed and ducts lacked fire dampers.

F. On July 25, 2017 at 1:45 PM while in the company of the LSC, it was observed that the exit passageway vestibule for the east stair which also serves the Kitchen was not fully separated from adjacent spaces to comply with 19.3.1, 7.2.6.2, and 8.3.4 because unprotected wall penetrations were observed at the small unoccupied closet accessed from the enclosure. The exterior exit discharge door at this vestibule sticks to make it difficult to open and remain in compliance with 7.2.1.4.5.1.

G. On July 25, 2017 at 1:50 PM while in the company of the LSC, it was observed at the Ground floor level that the spiral stair near the loading dock area was not provided with a self-closing, labeled fire resistance rated door to comply with 19.3.1 and 8.6.8.

H. On July 25, 2017 at 2:15 PM while in the company of the LSC, it was observed, at the Ground floor level refrigeration compressor room accessed from Tunnel 'A', that penetrations through the floor above were not sealed in accordance with 19.3.1 & 8.3.5.1.


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I. On July 25, 2017 at 10:27 AM, while accompanied by the DEF, observation determined that the access panel at the Second Floor Post-Anesthesia Care Unit (directly south of the Isolation Room) is not self-closing as required by 19.3.1.1, 8.3.3.4, and Table 8.3.4.2.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect any patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Findings include:

A. On July 24, 2017 at 2:25 PM while in the company of the LSC, it was observed that the 7th floor level north smoke compartment (7B) unsprinklered Clean Supply storage room which was greater than 50 sf was not 1-hour rated construction to comply with 19.3.2.1 because the door was not fire rated and the enclosing walls could not be confirmed to be 1-hour construction.

B. On July 24, 2017 at 2:50 PM while in the company of the LSC, it was observed that the 7th floor level east smoke compartment (7A) unsprinklered Physicians Office being used as a storage room which was greater than 100 sf was not 1-hour rated construction to comply with 19.3.2.1 because the door was not fire rated and the enclosing walls could not be confirmed to be 1-hour construction.

C. On July 24, 2017 at 3:15 PM while in the company of the LSC, it was observed that the 6th floor level (now designated as a Business occupancy floor level) sprinklered old patient room 621 was being used as a storage room which was greater than 100 sf was not provided with a self-closing door(s) to comply with 19.3.2.1.2, 19.3.2.1.3 & 8.4.3.5.

D. On July 25, 2017 at 1:50 PM while in the company of the LSC, it was observed that the 1st floor level old Dietary areas (including but not limited to the old Dish room) which are not sprinkler protected were being used for combustible storage and not separated from other use areas by 1-hour fire resistance rated construction to comply with 19.3.2.1.


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E. While accompanied by the DEF, observation determined that non-sprinklered hazardous areas do not carry a minimum 1 hour fire resistance rating as required by 19.3.2.1. Locations observed include:

1. July 24, 2017 at 2:06 PM: Seventh Floor Library 788.

2. July 25, 2017 at 8:52 AM: Fifth Floor former Patient Sleeping Room 592.

3. July 25, 2017 at 9:49 AM: Third Floor Storage Room immediately east of Patient Sleeping Room 386.

4. July 25, 2017 at 10:16 AM: Second Floor Intensive Care Unit Room 212.

F. On July 24, 2017 at 2:08 PM, while accompanied by the DEF, observation determined that the door to the Seventh Floor Dialysis Storage Room, a hazardous area, is not self-closing as required by 19.3.2.1.3, Table 8.3.4.2, and NFPA 80 2010 6.4.1.1.

Based on observation, not all portions of the building's fire alarm system are installed as required. This deficient practice could affect any 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 July 25, 2017 at 8:57 AM, while accompanied by the DEF, observation determined that the fire alarm manual pull station across the Corridor from Fifth Floor Exit Stair 006 is not within 5 feet of the exit door as required by 9.6.2.3(1) and NFPA 72 2010 17.14.6.

Based on observation, the facility failed to provide a complete automatic sprinkler system where installed. This deficient practice could affect any 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. While in the company of the LSC, it was observed that ceiling tile was missing to permit the ceiling to be open to the cavity above. The above ceiling cavity is not sprinklered. This condition does not comply with NFPA 13-2011, 8.6.4.1. Locations observed include:

1. On July 24, 2017 at 3:00 PM: At the Sixth Floor Room 629.

2. On July 24, 2017 at 3:15 PM: At the Sixth Floor Dumbwaiter Room.

3. On July 25, 2017 at 9:15 AM: At the Fifth Floor old Nursery Rooms.

4. On July 25, 2017 at 11:15 AM: At the Second Floor old Same-Day Surgery Prep/Recovery Area.


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B. On July 25, 2017 at 10:20 AM, while accompanied by the DEF, observation determined that large portions of the acoustic ceiling tile in the Second Floor Intensive Care Unit are missing or out of place, thus compromising the coverage of the room by standard pendant sprinkler heads, as prohibited by NFPA 13 2010 8.6.4.1.1, because the activation of the sprinkler heads could be delayed due to heat rising past them.

Based on observation, not all spaces open to corridors are protected to comply with Code provisions. This deficient practice could affect any patients, staff, and visitors in the building because failure to provide protective measures can result in delayed notification of a fire/smoke event which can compromise the use of the corridors or the response to the fire/smoke condition if the corridors are not properly separated.

Findings include:

A. On July 25, 2017 at 10:35 AM while in the company of the LSC, it was observed on the unsprinklered 3rd floor Adolescent unit that the patient group room (indicated as being used as part of treatment) was not separated from the corridor to comply with 19.3.6.1. The accordion doors do not resist the passage of smoke and are not constructed as 20 minute rated doors to comply with 19.3.6.3.1.

B. On July 25, 2017 at 10:40 AM while in the company of the LSC, it was observed on the unsprinklered 3rd floor east wing outpatient use area that the waiting/seating area open to the corridor did not comply with 19.3.6.1(9) because smoke detection was not provided at the seating area.

Based on observation, not all smoke barriers are constructed and maintained as required. This deficient practice could affect any patients, staff, and visitors in the building because smoke could pass between adjacent smoke compartments if the smoke barriers are not properly constructed.

Findings include:

A. On July 25, 2017 at 10:35 AM while in the company of the LSC, it was observed on the unsprinklered 3rd floor level at the smoke barrier to the east wing that the duct penetrating the barrier lacked a smoke damper to comply with 8.5.5.2.


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B. On July 24, 2017 at 2:49 PM, while accompanied by the DEF, observation determined that a duct which penetrates the Seventh Floor designated smoke barrier wall, between Smoke Compartments 7B and 7C, is not equipped with a smoke damper as required by 19.3.7.3 and 8.5.5.2.

Based on observation, not all portions of the building's medical gas system are installed as required. This deficient practice could affect any patients, staff, and visitors in the building because the medical gas system could fail to operate properly when needed if not properly installed.

Findings include:

On July 24, 2017 at 10:28 AM, while accompanied by the DEF, observation determined that the medical gas shutoff valves serving the Second Floor Post-Anesthesia Care Unit, which have been abandoned, are not identified with signage as being out of service as required by 19.3.2.4 and NFPA 99 2012 5.1.11.2.1(2).

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

Findings include:

While accompanied by the DEF, observation determined that wall-mounted clocks have been removed, and wires were exposed and not covered with cover plates as required by NFPA 99 2012 Chapter 6 and NFPA 70 2011 314-28(C). Locations observed include:
1. July 24, 2017 at 2:01 PM: Seventh Floor Corridor directly east of South Nurses' Station.

2. July 25, 2017 at 8:50 AM: Fifth Floor Corridor directly east of South Nurses' Station.

3. July 25, 2017 at 10:18 AM: Second Floor Intensive Care Unit south wall of Corridor directly west of Nurses' Station.

Based on observation, not all electrical receptacles are installed and maintained as required. This deficient practice could affect any patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

Findings include:

A. On July 25, 2017 at 1:18 PM, while accompanied by the DEF, observation determined that First Floor Emergency Department Treatment Bay 2 lacks an electrical receptacle served by the Normal Power Branch of the building's Type 1 Essential Electrical System (EES) are provided as required by NFPA 99 2012 6.3.2.2.1.2 and NFPA 70 2011 517-19(A).

B. On July 25, 2017, while accompanied by the DEF, observation determined that electrical receptacles served by the Critical Branch of the building's Type 1 Essential Electrical System (EES) are not labeled as to the electrical panel and circuit which serves them as required by NFPA 99 2012 6.3.2.2.1.2 and NFPA 70 2011 517-19(A). Locations observed include:

1. 1:18 PM: First Floor Emergency Department Treatment Bay 2.

2. 1:19 PM: First Floor Emergency Department Treatment Bay 4.