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On 9/22-23/14, while accompanied by facility staff during the survey walk through of Center Building fire/smoke compartment, it was determined that the Fire Walls between building additions, floors and rooms contained unsealed penetrations in the 2-hour rated enclosures. These deficiencies could affect patients, as well as staff and visitors because the failure to provide properly maintain the barriers could result in smoke or fire passing from one building to another. Items observed include:

A. Wire and conduits are improperly firestopped around the outer edges and the interior space, where the wires pass through because it did not contain firestopping in accordance with NFPA 101, 8.2.3.2.4.2 locations include but not limited to:

1. 5th floor, East end above the 2 hour cross corridor doors, unsealed pipe penetration.

2. 4th floor, West end above the 2 hour cross corridor doors, from inside the Chicago Vestibule looking East, unsealed pipe and wire penetrations.

3. 4th floor, West end above the 2 hour cross corridor doors, from inside the Chicago Vestibule looking East several wall penetrations were sealed with an expandable foam product. The facility was unable to provide documentation that the foam product utilized, was a UL approved assembly for two hour firestopping.

B. Main floor, West end above the 2 hour cross corridor doors, the wall intersection from the electrical closet to the 2 hour barrier wall. The upper 12 " of wall contains a 2x4 and an unsealed wall to wall connection. The facility will be required to install an approved "fire stopping system" which has been tested and approved by a testing laboratory in accordance with NFPA 101, 8.2.2.2.

C. Floors 1-8, West End, the wall between the Janitors closet and elevator shaft, contained a recessed 14 X 28 inch metal box approximately 5 feet above the finished floor. The recessed boxes are utilized as pull boxes for the phone lines and are not rated and were not properly fire stopped to restore the fire-wall to the 2-hour requirement in accordance with NFPA 101, 8.2.3.2.4.2.

D. Floors 1-8, the designated 2-hour fire walls contain cross corridor doors which are located between Center Building and the East Building as well as between Center and the West building.

1. The hardware (knobs, plates, upper or lower rods, hinges, etc.) failed to contain any markings indicating the fire rating of the hardware. The hardware is not in accordance with NFPA 101, Section 8.2 and 19.1.2.3 and 7.2.1.7, NFPA 80, 1999 Edition Fire Doors and Windows.

2. Similar conditions wwere observed at doors to Exit Stair enclosures.

Based on random observation, with the EVS Manager, the surveyor finds that corridor doors lack positive latching hardware in accordance with 19.3.6.3.2. Failure to maintain corridor doors could allow a fire to spread beyond the room of fire origin.

Findings include:

A. East Wing, 4th Floor Laboratory Department - Hematology Lab

B. East Wing, 3rd Floor - Women Gown Waiting

C. East Wing, 4th Floor, Blood collection /Glass Wash room doors (2)

D. East Wing, 4th Floor, Microbiology and Parasitology Room

On 9/22/14 during the survey walk-through, it was observed that not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect patients, as well as staff and visitors because the failure to provide proper shaft enclosure could result in smoke or fire passing from one part of the building to another.

Findings include:

A. 8th floor, Center, the designated 2 hour rated duct shaft on the West end of the corridor contained several access panels. Inside the shaft it was observed that the concrete blocks above the access doors were not capped or filled with mortar. It was also observed that the inside corner of the duct shaft was missing mortar between the blocks in several locations. It could not be determined how the 2 hour fire rating of the shaft enclosure was maintained in accordance with NFPA 101, 19.3.1.1 and 8.2.5.4 Subpart 1.


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Based on random observation during the survey walk-through, not all floor/ceiling assemblies are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. This deficiency could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between building stories.

Findings include:

B. At 10:45 AM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed 2 ducts, in the Toilet Room serving West Wing Fourth Floor Office 414, which penetrate the floor/ceiling above and which lack fire dampers required by NFPA 90A 1999 3-3.2.


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C. Based on random observation during the survey walk through not all vertical openings are protected to comply with 19.3.1 and 8.2.5.2. This could contribute to the lack of containment during a fire event. This condition could affect all patients, staff and visitors on all floor levels.

1. East Wing, 4th Floor - The ventilation shaft wall near the Men's Toilet and the Electrical Closet was observed with a hole that is not sealed to comply with 8.2.5.4 and 19.3.1.1.

2. East Wing, 9th Floor Mechanical room - A hole at duct penetration through a designated 2-hour rated barrier floor construction was observed which lacked protection to comply with 8.2.3.2.4.2.

D. East Wing, 6th Floor - A designated ventilation shaft was observed with an exhaust duct penetration that lacks a fire damper. Location observed near the exit Stair #1.

On 9/23/14, while accompanied by facility staff during the survey walk through of Center Building fire/smoke compartment, it was determined that the Smoke barrier between floors and rooms contained unsealed penetrations items observed include:

A. 3rd floor, West end of Center Building, office next to the toilet room contains an unsealed television cable penetration in the plaster ceiling. NFPA 101, 2000, 8.3.6.1.


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Based on random observation during the survey walk-through and document review, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. This deficiency could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

B. At 2:26 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the designated fire/smoke barrier wall between the Ground Floor Kitchen and Dishwashing Room is incomplete because an approximately 10'-0" section of wall, designated on the facility Life Safety Plans as a smoke barrier wall, does not exist.

A. On 9/23/14 Center Building, observations determined that the Main Floor, Medical Records Room (suite 3,019 square feet) was greater than 100 square feet and had a high combustible load of open paper files (rolling stackable storage shelves), cardboard boxes of paper files and was viewed as a hazardous area. The Medical Records Room was deficient because of the following.

1. The door between Reception and Doctors Check-in was being held open by an unapproved hold open device (foot peg). NFPA 101, 8.2.3.2.3.1(2)

2. The door between Medical Records and Work/files/lockers was held open by an unapproved hold open device.

B. On 9/22/14 Center Building, observations determined that the 7th floor, Surgery Suite converted the " Cysto OR " into a storage room and it does not comply with the requirements for storage under NFPA 101, Chapter 19. The room is not rated, or provided with a self closing, positive latching door for storage rooms in excess of 100 square feet.

C. On 9/22/14 Center Building, observations determined that the 7th floor, Surgery Suite Clean work/ storage room does not comply with the requirements for storage under NFPA 101, Chapter 19. The room is not provided with positive latching hardware for storage rooms in excess of 100 square feet and sprinkler protected.

D. On 9/23/14 Center Building, 3rd floor, Patient Belongings Storage Room was identified as being a hazardous area and a one hour fire resistance rated enclosure based on the Life Safety Drawings. The door to this room is not self closing as required by NFPA 101, 8.2.3.2.3.1 (2).

E. On 9/23/14 Center Building, 3rd floor, Janitors Closet & Soiled Utility Room is enclosed with one hour fire resistance rating. The door closer, failed to close the door to a latched position.


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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. This deficiency could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

F. At 1:25 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the door to the Main Floor West Wing Business Office Store Room lacked a self-closing device required by 19.3.2.1.


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Based on random observation with the EVS Manager present, the surveyor observed that hazardous areas are not enclosed in accordance with 19.3.2.1. Lack of properly enclosure could result in an uncontrolled fire spreading beyond the room of fire origin and injuring staff and patients.

Findings include:

G. Hazardous areas were observed at which doors are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include:

1. East Wing, 5th Floor, The corridor door to the Clean Linen storage room did not self-close all the way to the frame.

2. East Wing, 4th Floor, the Histology / Pathology Room which is now being used as a storage room for the Hematology and for the Cardio / Pulmonary was observed with respiratory equipment devices, hematology chemicals and trash carts. The door to this room is not self-closing to comply with NFPA 101 19.3.2.1.

3. East Wing, 4th Floor, Laboratory Department - The Autopsy Room which is being used as a Storage Room lacks self-closing hardware to comply with NFPA 2000 19.3.2.1.

4. East Wing, 3rd Floor-Elevator Lobby: The self-closing door to the Janitor's Closet does not self close all the way to the frame.

5. East Wing, 3rd Floor: The door to the Storage Room near the Waiting Room for the Radiology Department is not self-closing.

6. East Wing, Main Floor- Emergency Department: The Soiled Utility Room door does not self-close all the way to the frame.

Based on random observation during the survey walk through, not all fire/smoke compartments are provided with at least two designated means of egress. This deficiency could affect any patients, staff, or visitors in the smoke compartment by delaying egress from the compartment.

Findings include:

A. At 10:41 AM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the West Wing Fourth Floor, designated as a smoke compartment, lacks access to an adjacent smoke compartment as required by 19.2.4.3. because no exit sign was observed above the egress side of the pair of cross-corridor doors to the Center Wing.


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Based on random observation during the survey walk through, not all fire/smoke compartments are provided with at least two designated means of egress. This deficiency could affect any patients, staff, or visitors in the smoke compartment by delaying egress from the compartment.

Findings include:

B. At the East Wing Seventh Floor, the following conditions were observed:

1. The designated fire/smoke compartment was observed to lack at least 2 remote exits, as required by 19.2.4.1., because it was observed to be served by a single Exit Stair and no exit sign directs occupants into an adjacent fire compartment.
2. The designated fire/smoke compartment does not have access to an adjacent smoke compartment as required by 19.2.4.3. because egress from a smoke compartment is prohibited from being into a suite by 19.2.5.9.

C. The Surveyor observed that designated East Wing smoke compartments lack access to an adjacent smoke compartment as required by 19.2.4.3. because no exit sign was observed above the egress side of the pair of cross-corridor doors to the Center Wing. Locations observed include:
1. East Wing Sixth Floor.
2. East Wing Fifth Floor.
3. East Wing Fourth Floor.

4. East Wing Third Floor.

Based on observations, the facility failed to provide exit components having a fire resistance rating of at least one hour ( 2 hour for buildings with more than 4 stories). The exit components are to be arranged to provide a path of escape, and to provide protection against fire or smoke from other parts of the building.

Findings include:

A. On 9/23/14, Center Building, Main floor, Exit Passageway serving Exit Stair #2. The passageway is equipped with ceiling tiles, above the ceiling is electrical conduit, plumbing, etc. that do not serve the exit passageway or stair and are not properly separated from the enclosure. NFPA 101, 19.3.1.1; 8.2.5.4(1) and 7.1.3.2.1(e).

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. While accompanied by the Director of Support Services and a Carpenter, the Surveyor observed the following deficiencies at Exit Stair 4:
1. 11:27 AM September 23, 2014: The door to the Third Floor landing was observed to have an unrepaired hole prohibited by NFPA 80 1999 15-2.5.4.

2. 1:13 PM September 23, 2014, Main Floor landing:
a. 4 conduits which do not serve the exit enclosure were observed within it as prohibited by 7.1.3.2.2.1(e).

b. The conduits noted in Item A.2.a. above were observed to not be firestopped at either the east or west walls of the enclosure as required by 8.2.3.2.4.2.
c. The west door to the exit enclosure was observed to not close to latch as required by 8.2.3.2.3.1. and NFPA 80 199 2-4.4.3.

B. At 1:32 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed the following deficiencies at Exit Stair 5:

1. 4 garbage carts were observed within the exit enclosure as prohibited by 7.1.3.2.3.

2. At the Ground Floor, Exit Stair 5 is indicated, by an exit sign, as being part of an egress path. The Stair is contiguous with and open to all other levels of the Exit Stair, which is designated on all other levels as a Communicating Stair and which cannot comply as an exit enclosure for at last the following reasons:
a. An elevator is open to the enclosure on several levels, as prohibited by 9.4.7.

b. Storage rooms open directly into the exit enclosure on several levels, as prohibited by 7.1.3.2.1(d).

C. At 11:22 AM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the Fourth Floor door to Exit Stair 5 was observed to not be positive latching as required by 8..2.3.2.3.1. and NFPA 80 1999 2-4.4.3.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 2:03 PM on September 22, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the southeast door to the West Wing Seventh Floor Financial Office Corridor, which is equipped with a lock operated in the direction of egress by a push button, lacks a sensor required by 7.2.1.6.2(a).

B. At 2:24 PM on September 22, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed 2 doors to West Wing Sixth Floor Exit Stairs that are secured against passage in the direction of egress as prohibited by 19.2.2.2.4. Doors at which this condition was observed include:
1. The door to Exit Stair 6.
2. The door to Exit Stair 7.
C. At 11:29 AM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the Fourth Floor Corridor located directly north of the Boiler Room (and which serves a health care occ upancy) is not provided with at least 2 remote exits, as required by 19.2.5.9., because no exit sign exists at the west end of the Corridor.

D. At 11:40 AM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed an abrupt change in elevation, in excess of 1/4" as prohibited by 7.1.6.2., just inside the door at the West Wing Fourth Floor landing for Exit Stair 7.
E. At 1:40 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the elevation of the walking surface at the West Wing exterior door from Exit Stair 5 is not maintained on the exterior side of the door for at least the width of the door as required by 7.2.1.3., because no stoop is provided.

F. At 1:41 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed the drop-off at the West Wing Loading Dock is in excess of 30 inches and lacks a guard rail required by 7.2.2.4.1., because the existing guards were not in place.


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Based on random observation during the survey walk-through, while accompanied by facility representative, 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:

G. Main Building - On 09/23/14, the Emergency Department signage located outside the Stair 1 exit discharge obstructs the exterior path to the public way and does not comply with 7.7.1. and 7.7.3.

Based on direct observation, the facility failed to provide illumination of exit discharges that would not be affected by the failure of a single bulb in accordance with NFPA 101, 39.2.8 and 7.8. This deficient practice could affect occupants utilizing the unlit egress path during an emergency.

A. On 9/23/14 it was observed that the rear exterior egress path did not contain a two-lamp light fixture. The existing fixture was deficient per NFPA 101, Section 7.8.1.4, in only providing a one-lamp fixture at the exit discharge.

Based on interviews, the facility failed to provide proper maintenance, inspections and testing for emergency lights used within the facility in accordance with NFPA 101 Sections 7.9.2 . The facility is required to provide monthly and annual timed inspections with documentation in written logs for all emergency battery-pack light fixtures and operable units with charged batteries. This deficient practice could affect staff and patients, if the lights failed and prolonged the evacuation in an emergency situation.

Findings include:

A. On 9/23/14, During the interview the surveyors were informed that they had not conducted the required 30-second monthly tests or an annual 90-minute test, per NFPA 101, Section 7.9.3.

1. No "30-second monthly test" Per NFPA 101, Section 7.9.3.

2. No "90-minute annual test" Per NFPA 101, Section 7.9.3.

Based on random observation during the survey walk-through, staff interview, and document review, not all emergency lighting is maintained in accordance with 7.9. These deficiencies could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

A. While accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that exterior egress paths are not illuminated by emergency lighting as required by 7.8.1.3. and 7..8.1.4. Locations observed include:
1. 1:35 PM September 23, 2014: The door from Exit Stair 4.
2. 1:40 PM September 23, 2014: The door from Exit Stair 5.

B. During a review of the facility's building systems test records, it was determined that battery-powered emergency lights are not tested for a period of 30 seconds at least once every 30 days as required by 7.9.3. During an interview held in the West Wing Seventh Floor Conference Room at 9:31 AM on September 24, 2014, the provider's Director of Support Services confirmed this finding.
C. During a review of the facility's building systems test records, it was determined that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3. During an interview held in the West Wing Seventh Floor Conference Room at 9:31 AM on September 24, 2014, the provider's Director of Support Services confirmed this finding.

Based on observations it was determined that the facility failed to provide and/or maintain the directional emergency illuminated exit signs in accordance with LSC, Section 7.10.2.

A. On 9/23/14, observations determined that the exit sign was not illuminated above the rear exit door. In the event of a fire, the exit would not be identifiable.

Based on an observation, the facility failed to install all required initiating devices to provide a "complete fire alarm system" to monitor vital equipment continuously in accordance with NFPA 101, 2000 Edition, Section 9.6 as well as NFPA 70 and NFPA 72, Section 1-5.6.

A. On 9/23/14, Center Building, 4th floor, West End, Office located in back of Nursing Station contains a smoke detector that is located within 3 ' -0 " of the supply air diffuser. NFPA 72, 1999, 2-3.5.1.


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Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

B. At 2:40 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed a smoke detector, in West Wing Fifth Floor Soiled Utility Room 512C, which is located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

Based on direct observation and interview, the facility failed to provide and maintain a "complete fire alarm system" in accordance with NFPA 101, 2000 Edition, Sections 4.2 and 9.6 as well as NFPA 70 and NFPA 72, Section 1-5.6. This deficient practice could affect all staff and visitors.

Findings include:

A. On 9/23/14 during interviews with facility representatives, it was determined that the smoke detectors and pull stations are not being inspected. It is unclear how the system is installed or if the system is functional.

1. lity does not maintain as-built drawings, Operation and Maintenance manuals, or operational sequence documentation per NFPA 72 1999 7-5.1.

2. Facility does not conduct periodic visual inspections of system per NFPA 72 1999 Table 7-3.1.

3. Facility does not conduct periodic tests of system components NFPA 72 1999 Table 7-3.2.

Based on fire alarm interview, the facility failed to properly test the fire alarm system in accordance with NFPA 101, 2000 Edition, Sections 4.2 and 9.6 as well as NFPA 70 and NFPA 72. This deficient practice could affect an indeterminable number of staff and visitors.

Finding include:

On 9/23/14 during interviews with facility representatives, it was determined that the smoke detectors and pull stations are not being inspected. It is unclear how the system works or if the system is functional.

A. Functional Test: Tests to be conducted on each individual smoke detector with specific information logged such as "Individual Addresses", "Manufacture's Range", "Activation Point" and "Pass/Fail".

B. Sensitivity Test: no Sensitivity Test was performed on all smoke detectors in the past 2-years. This test includes the "Manufacture's Range for each tested device.

On 9/22-23/14 observations during the walk through, the facility failed have all sprinklers installed to meet the requirements of NFPA 101, 2000 Edition, Sections 19.3.5; NFPA 13, 1999 Edition. This deficient practice would affect an indeterminable number of staff , visitors and patients, if the sprinklers failed to operate properly in the event of a fire due to improper installation.

Findings Include:

A. 7th floor Center, Surgical Suite, Nurses Lounge, the hole cut in the plaster ceiling to accommodate the sprinkler head exceeded the size of the escutcheon cap, leaving a gap of approximately ¼ " .

B. 4th floor Center, East end, North patient room toilet, the hole cut in the plaster ceiling to accommodate the sprinkler head exceeded the size of the escutcheon cap, leaving a gap of approximately ¼ " .

C. 3rd floor Center, West end, Break Room, the hole cut in the plaster ceiling to accommodate the sprinkler piping is not sealed, leaving a gap of approximately ¼ " .

D. Main floor, Center, East End, electrical closet, the hole cut in the plaster ceiling to accommodate the sprinkler head exceeded the size of the escutcheon cap, leaving a gap of approximately ¼ "

E. Main floor, Center, Medical Records, the " suite " contains a movable shelving unit with patient files. The sprinkler heads are located above the files, however since the shelves move, it is unclear if the location of the heads is adequate for this area. NFPA 13.


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Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

F. East Wing, 6th Floor: While accompanied by the provider's EVS Manager, the skylight in the Conference Room was observed that lack sprinkler coverage required by NFPA 13 1999 5-1.1.(1).

G. East Wing, 3rd Floor Radiology Department - Electrical Room / Closet between Men and Women's Gowning Room lack sprinkler protection to comply with NFPA 13 1999 5-1.1.(1).

H. East Wing, 4th Floor - a 1' x 1' hole in the gypsum ceiling was observed which compromises the activation of the sprinkler head under fire and smoke conditions and therefore does not comply with NFPA 13 1999. Location include:

1. Storage Closet in the Expressive Therapy

I. During the survey walk-through, not all portions of the facility's automatic sprinkler system are maintained in accordance with NFPA 25 1998 2-4.1.8. Sprinkler escutcheons on ceiling tiles are missing. Locations observed include:

1. East Wing, 5th Floor - Aisle in ICU Suite.

2. East Wing, 4th Floor - Aisle in Cardio/Pulmonary.

3. East Wing, 4th Floor - Expressive Therapy Room.

4. East Wing, 3rd Floor - Janitor's Closet in the Radiology Department.

5. East Wing, Ground Floor - Physical Therapy, Waiting Area.

Based on observations, it was determined that the facility failed to properly secure and inspect all portable fire extinguishers in accordance with NFPA 101, 2000 Edition 19.3.5.6, 9.7.4.1 and NFPA 10. This deficient practice could affect all Smoke Zones, and could affect an indeterminable number of patients, staff and visitors.

Findings include:

A. On 9/22/14, 7th floor, Surgical Suite, Facility staff failed to conduct all required inspections on each individual Fire Extinguisher. The last inspection of the fire extinguishers was 7/11/14. This was determined by the observation of each inspection tag located on the individual fire extinguishers provided by the facility.

Based on observations, it was determined that the facility failed to properly secure and inspect all portable fire extinguishers in accordance with NFPA 101, 2000 Edition 19.3.5.6, 9.7.4.1 and NFPA 10. This deficient practice could affect an indeterminable number of patients, staff and visitors.

Findings include:

A. On 9/23/14, Facility staff failed to conduct all required inspections on each individual Fire Extinguisher. The last inspection of the fire extinguishers was 7/11/14. This was determined by the observation of each inspection tag located on the individual fire extinguishers provided by the facility.

Based on observation and staff interview, it was determined that facility provide soiled linen or trash collection receptacles exceeding 32 gal in capacity in accordance with NFPA 101, 2000 Edition, Section 19.7.5.5. and 19.3.2.1. This deficient practice could affect an indeterminable number of staff and patients, if a fire would develop in a non-hazardous room in receptacles exceeding the maximum allowed capacity.

Findings include:

A. 7th floor Center, Surgery Suite, OR #3, contained 4 soiled linen receptacles each approximately 32 gallons and a 16 gallon trash can located within a 64 square foot area.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

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 document review and staff interview, the emergency generator is not inspected and tested in accordance with NFPA 99. These deficiencies could affect any patients, staff, or visitors in the building because the emergency generator could fail to operate under emergency conditions.

Findings include:

A. During the document review process, it was determined that the emergency generator was not visually inspected on a weekly basis, as required by NFPA 110 1999 6-4.1., between January 1, 2014 and May 31, 2014. This determination was confirmed by the provider's Director of Support Services during an interview held in the West wing Seventh Floor Conference Room at 9:41 AM September 24, 2014.

B. During the document review process, it was determined that the emergency generator storage batteries are not visually inspected on a weekly basis, as required by NFPA 99 1999 3-4.4.1.3. and NFPA 110 1999 6-3.6., between January 1, 2014 and May 31, 2014. This determination was confirmed by the provider's Director of Support Services during an interview held in the West wing Seventh Floor Conference Room at 9:41 AM September 24, 2014.

C. During the document review process, it was determined that the emergency generator is not tested under load for 30 minutes each month, as required by NFPA 99 1999 3-4.4.1.1. and NFPA 110 6-4.2., between January 1, 2014 and May 31, 2014. This determination was confirmed by the provider's Director of Support Services during an interview held in the West wing Seventh Floor Conference Room at 9:41 AM September 24, 2014.

Based on observations, the facility failed to install electrical wiring in accordance with NFPA 101, 2000 Edition, Section 9.1.2 and NFPA 70, 1999 Edition, National Electrical Code. This deficient practice could affect an indeterminable number of staff and patients that would come in contact with deficient electrical wiring.

Finding include:

A. 7th floor Center Building, Surgery Suite, does not contain normal power outlets. This does not meet with NFPA 70 (1999) 517-19.




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By direct observation and staff interview while in the company of the Facility ' s Director of Support Services and Stationary Engineer the Surveyor finds the facility does not have a compliant Type 1 Essential Electrical System. (NFPA 99, 1999, 3-4)
Observations and staff interview include but not limited to:
a. There are automatic transfer switches installed and identified for the Life Safety Branch, Critical Branch and Equipment Branch.
b. Identification of the distribution and separation for the three required branches is not provided at circuit panel locations throughout the facility.
c. Interview with the Director of Support Service and Stationary Engineer indicated that when the emergency generator is supplying electricity to the facility during a utility outage the entire facility has electrical power not just the Essential Electrical System distribution within the facility. Only those electrical loads as identified in NFPA 99, 1999, 3-4.2.2.1 shall be supported of a Type 1 Essential Electrical System.

Based on observations, the facility failed to install electrical wiring in accordance with NFPA 101, 2000 Edition, Section 9.1.2 and NFPA 70, 1999 Edition, National Electrical Code. This deficient practice could affect an indeterminable number of staff and patients that would come in contact with deficient electrical wiring.

Finding include:

A. 7th floor Center Building, Surgery Suite, an extension cord was being utilized in an OR, which is identified on the drawings as " recovery " within the Surgical Suite. This does not meet with NFPA 70 (1999) 240-4 or 305-3(b).

B. 7th floor Center Building, Surgery Suite, no battery powered emergency lights were provided in the OR ' s as required by NFPA 99, (1999), 3-3.2.1.2(a)(5)(e) and NFPA 70 (1999)517-63(a).

On 9/22-23/14, while accompanied by facility staff during the survey walk through of Center Building fire/smoke compartment, it was determined that the Fire Walls between building additions, floors and rooms contained unsealed penetrations in the 2-hour rated enclosures. These deficiencies could affect patients, as well as staff and visitors because the failure to provide properly maintain the barriers could result in smoke or fire passing from one building to another. Items observed include:

A. Wire and conduits are improperly firestopped around the outer edges and the interior space, where the wires pass through because it did not contain firestopping in accordance with NFPA 101, 8.2.3.2.4.2 locations include but not limited to:

1. 5th floor, East end above the 2 hour cross corridor doors, unsealed pipe penetration.

2. 4th floor, West end above the 2 hour cross corridor doors, from inside the Chicago Vestibule looking East, unsealed pipe and wire penetrations.

3. 4th floor, West end above the 2 hour cross corridor doors, from inside the Chicago Vestibule looking East several wall penetrations were sealed with an expandable foam product. The facility was unable to provide documentation that the foam product utilized, was a UL approved assembly for two hour firestopping.

B. Main floor, West end above the 2 hour cross corridor doors, the wall intersection from the electrical closet to the 2 hour barrier wall. The upper 12 " of wall contains a 2x4 and an unsealed wall to wall connection. The facility will be required to install an approved "fire stopping system" which has been tested and approved by a testing laboratory in accordance with NFPA 101, 8.2.2.2.

C. Floors 1-8, West End, the wall between the Janitors closet and elevator shaft, contained a recessed 14 X 28 inch metal box approximately 5 feet above the finished floor. The recessed boxes are utilized as pull boxes for the phone lines and are not rated and were not properly fire stopped to restore the fire-wall to the 2-hour requirement in accordance with NFPA 101, 8.2.3.2.4.2.

D. Floors 1-8, the designated 2-hour fire walls contain cross corridor doors which are located between Center Building and the East Building as well as between Center and the West building.

1. The hardware (knobs, plates, upper or lower rods, hinges, etc.) failed to contain any markings indicating the fire rating of the hardware. The hardware is not in accordance with NFPA 101, Section 8.2 and 19.1.2.3 and 7.2.1.7, NFPA 80, 1999 Edition Fire Doors and Windows.

2. Similar conditions wwere observed at doors to Exit Stair enclosures.

Based on random observation, with the EVS Manager, the surveyor finds that corridor doors lack positive latching hardware in accordance with 19.3.6.3.2. Failure to maintain corridor doors could allow a fire to spread beyond the room of fire origin.

Findings include:

A. East Wing, 4th Floor Laboratory Department - Hematology Lab

B. East Wing, 3rd Floor - Women Gown Waiting

C. East Wing, 4th Floor, Blood collection /Glass Wash room doors (2)

D. East Wing, 4th Floor, Microbiology and Parasitology Room

On 9/22/14 during the survey walk-through, it was observed that not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect patients, as well as staff and visitors because the failure to provide proper shaft enclosure could result in smoke or fire passing from one part of the building to another.

Findings include:

A. 8th floor, Center, the designated 2 hour rated duct shaft on the West end of the corridor contained several access panels. Inside the shaft it was observed that the concrete blocks above the access doors were not capped or filled with mortar. It was also observed that the inside corner of the duct shaft was missing mortar between the blocks in several locations. It could not be determined how the 2 hour fire rating of the shaft enclosure was maintained in accordance with NFPA 101, 19.3.1.1 and 8.2.5.4 Subpart 1.


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Based on random observation during the survey walk-through, not all floor/ceiling assemblies are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. This deficiency could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between building stories.

Findings include:

B. At 10:45 AM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed 2 ducts, in the Toilet Room serving West Wing Fourth Floor Office 414, which penetrate the floor/ceiling above and which lack fire dampers required by NFPA 90A 1999 3-3.2.


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C. Based on random observation during the survey walk through not all vertical openings are protected to comply with 19.3.1 and 8.2.5.2. This could contribute to the lack of containment during a fire event. This condition could affect all patients, staff and visitors on all floor levels.

1. East Wing, 4th Floor - The ventilation shaft wall near the Men's Toilet and the Electrical Closet was observed with a hole that is not sealed to comply with 8.2.5.4 and 19.3.1.1.

2. East Wing, 9th Floor Mechanical room - A hole at duct penetration through a designated 2-hour rated barrier floor construction was observed which lacked protection to comply with 8.2.3.2.4.2.

D. East Wing, 6th Floor - A designated ventilation shaft was observed with an exhaust duct penetration that lacks a fire damper. Location observed near the exit Stair #1.

On 9/23/14, while accompanied by facility staff during the survey walk through of Center Building fire/smoke compartment, it was determined that the Smoke barrier between floors and rooms contained unsealed penetrations items observed include:

A. 3rd floor, West end of Center Building, office next to the toilet room contains an unsealed television cable penetration in the plaster ceiling. NFPA 101, 2000, 8.3.6.1.


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Based on random observation during the survey walk-through and document review, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. This deficiency could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

B. At 2:26 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the designated fire/smoke barrier wall between the Ground Floor Kitchen and Dishwashing Room is incomplete because an approximately 10'-0" section of wall, designated on the facility Life Safety Plans as a smoke barrier wall, does not exist.

A. On 9/23/14 Center Building, observations determined that the Main Floor, Medical Records Room (suite 3,019 square feet) was greater than 100 square feet and had a high combustible load of open paper files (rolling stackable storage shelves), cardboard boxes of paper files and was viewed as a hazardous area. The Medical Records Room was deficient because of the following.

1. The door between Reception and Doctors Check-in was being held open by an unapproved hold open device (foot peg). NFPA 101, 8.2.3.2.3.1(2)

2. The door between Medical Records and Work/files/lockers was held open by an unapproved hold open device.

B. On 9/22/14 Center Building, observations determined that the 7th floor, Surgery Suite converted the " Cysto OR " into a storage room and it does not comply with the requirements for storage under NFPA 101, Chapter 19. The room is not rated, or provided with a self closing, positive latching door for storage rooms in excess of 100 square feet.

C. On 9/22/14 Center Building, observations determined that the 7th floor, Surgery Suite Clean work/ storage room does not comply with the requirements for storage under NFPA 101, Chapter 19. The room is not provided with positive latching hardware for storage rooms in excess of 100 square feet and sprinkler protected.

D. On 9/23/14 Center Building, 3rd floor, Patient Belongings Storage Room was identified as being a hazardous area and a one hour fire resistance rated enclosure based on the Life Safety Drawings. The door to this room is not self closing as required by NFPA 101, 8.2.3.2.3.1 (2).

E. On 9/23/14 Center Building, 3rd floor, Janitors Closet & Soiled Utility Room is enclosed with one hour fire resistance rating. The door closer, failed to close the door to a latched position.


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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1. This deficiency could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

F. At 1:25 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the door to the Main Floor West Wing Business Office Store Room lacked a self-closing device required by 19.3.2.1.


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Based on random observation with the EVS Manager present, the surveyor observed that hazardous areas are not enclosed in accordance with 19.3.2.1. Lack of properly enclosure could result in an uncontrolled fire spreading beyond the room of fire origin and injuring staff and patients.

Findings include:

G. Hazardous areas were observed at which doors are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include:

1. East Wing, 5th Floor, The corridor door to the Clean Linen storage room did not self-close all the way to the frame.

2. East Wing, 4th Floor, the Histology / Pathology Room which is now being used as a storage room for the Hematology and for the Cardio / Pulmonary was observed with respiratory equipment devices, hematology chemicals and trash carts. The door to this room is not self-closing to comply with NFPA 101 19.3.2.1.

3. East Wing, 4th Floor, Laboratory Department - The Autopsy Room which is being used as a Storage Room lacks self-closing hardware to comply with NFPA 2000 19.3.2.1.

4. East Wing, 3rd Floor-Elevator Lobby: The self-closing door to the Janitor's Closet does not self close all the way to the frame.

5. East Wing, 3rd Floor: The door to the Storage Room near the Waiting Room for the Radiology Department is not self-closing.

6. East Wing, Main Floor- Emergency Department: The Soiled Utility Room door does not self-close all the way to the frame.

Based on random observation during the survey walk through, not all fire/smoke compartments are provided with at least two designated means of egress. This deficiency could affect any patients, staff, or visitors in the smoke compartment by delaying egress from the compartment.

Findings include:

A. At 10:41 AM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the West Wing Fourth Floor, designated as a smoke compartment, lacks access to an adjacent smoke compartment as required by 19.2.4.3. because no exit sign was observed above the egress side of the pair of cross-corridor doors to the Center Wing.


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Based on random observation during the survey walk through, not all fire/smoke compartments are provided with at least two designated means of egress. This deficiency could affect any patients, staff, or visitors in the smoke compartment by delaying egress from the compartment.

Findings include:

B. At the East Wing Seventh Floor, the following conditions were observed:

1. The designated fire/smoke compartment was observed to lack at least 2 remote exits, as required by 19.2.4.1., because it was observed to be served by a single Exit Stair and no exit sign directs occupants into an adjacent fire compartment.
2. The designated fire/smoke compartment does not have access to an adjacent smoke compartment as required by 19.2.4.3. because egress from a smoke compartment is prohibited from being into a suite by 19.2.5.9.

C. The Surveyor observed that designated East Wing smoke compartments lack access to an adjacent smoke compartment as required by 19.2.4.3. because no exit sign was observed above the egress side of the pair of cross-corridor doors to the Center Wing. Locations observed include:
1. East Wing Sixth Floor.
2. East Wing Fifth Floor.
3. East Wing Fourth Floor.

4. East Wing Third Floor.

Based on observations, the facility failed to provide exit components having a fire resistance rating of at least one hour ( 2 hour for buildings with more than 4 stories). The exit components are to be arranged to provide a path of escape, and to provide protection against fire or smoke from other parts of the building.

Findings include:

A. On 9/23/14, Center Building, Main floor, Exit Passageway serving Exit Stair #2. The passageway is equipped with ceiling tiles, above the ceiling is electrical conduit, plumbing, etc. that do not serve the exit passageway or stair and are not properly separated from the enclosure. NFPA 101, 19.3.1.1; 8.2.5.4(1) and 7.1.3.2.1(e).

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. While accompanied by the Director of Support Services and a Carpenter, the Surveyor observed the following deficiencies at Exit Stair 4:
1. 11:27 AM September 23, 2014: The door to the Third Floor landing was observed to have an unrepaired hole prohibited by NFPA 80 1999 15-2.5.4.

2. 1:13 PM September 23, 2014, Main Floor landing:
a. 4 conduits which do not serve the exit enclosure were observed within it as prohibited by 7.1.3.2.2.1(e).

b. The conduits noted in Item A.2.a. above were observed to not be firestopped at either the east or west walls of the enclosure as required by 8.2.3.2.4.2.
c. The west door to the exit enclosure was observed to not close to latch as required by 8.2.3.2.3.1. and NFPA 80 199 2-4.4.3.

B. At 1:32 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed the following deficiencies at Exit Stair 5:

1. 4 garbage carts were observed within the exit enclosure as prohibited by 7.1.3.2.3.

2. At the Ground Floor, Exit Stair 5 is indicated, by an exit sign, as being part of an egress path. The Stair is contiguous with and open to all other levels of the Exit Stair, which is designated on all other levels as a Communicating Stair and which cannot comply as an exit enclosure for at last the following reasons:
a. An elevator is open to the enclosure on several levels, as prohibited by 9.4.7.

b. Storage rooms open directly into the exit enclosure on several levels, as prohibited by 7.1.3.2.1(d).

C. At 11:22 AM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the Fourth Floor door to Exit Stair 5 was observed to not be positive latching as required by 8..2.3.2.3.1. and NFPA 80 1999 2-4.4.3.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 2:03 PM on September 22, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the southeast door to the West Wing Seventh Floor Financial Office Corridor, which is equipped with a lock operated in the direction of egress by a push button, lacks a sensor required by 7.2.1.6.2(a).

B. At 2:24 PM on September 22, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed 2 doors to West Wing Sixth Floor Exit Stairs that are secured against passage in the direction of egress as prohibited by 19.2.2.2.4. Doors at which this condition was observed include:
1. The door to Exit Stair 6.
2. The door to Exit Stair 7.
C. At 11:29 AM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the Fourth Floor Corridor located directly north of the Boiler Room (and which serves a health care occ upancy) is not provided with at least 2 remote exits, as required by 19.2.5.9., because no exit sign exists at the west end of the Corridor.

D. At 11:40 AM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed an abrupt change in elevation, in excess of 1/4" as prohibited by 7.1.6.2., just inside the door at the West Wing Fourth Floor landing for Exit Stair 7.
E. At 1:40 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the elevation of the walking surface at the West Wing exterior door from Exit Stair 5 is not maintained on the exterior side of the door for at least the width of the door as required by 7.2.1.3., because no stoop is provided.

F. At 1:41 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed the drop-off at the West Wing Loading Dock is in excess of 30 inches and lacks a guard rail required by 7.2.2.4.1., because the existing guards were not in place.


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Based on random observation during the survey walk-through, while accompanied by facility representative, 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:

G. Main Building - On 09/23/14, the Emergency Department signage located outside the Stair 1 exit discharge obstructs the exterior path to the public way and does not comply with 7.7.1. and 7.7.3.

Based on direct observation, the facility failed to provide illumination of exit discharges that would not be affected by the failure of a single bulb in accordance with NFPA 101, 39.2.8 and 7.8. This deficient practice could affect occupants utilizing the unlit egress path during an emergency.

A. On 9/23/14 it was observed that the rear exterior egress path did not contain a two-lamp light fixture. The existing fixture was deficient per NFPA 101, Section 7.8.1.4, in only providing a one-lamp fixture at the exit discharge.

Based on interviews, the facility failed to provide proper maintenance, inspections and testing for emergency lights used within the facility in accordance with NFPA 101 Sections 7.9.2 . The facility is required to provide monthly and annual timed inspections with documentation in written logs for all emergency battery-pack light fixtures and operable units with charged batteries. This deficient practice could affect staff and patients, if the lights failed and prolonged the evacuation in an emergency situation.

Findings include:

A. On 9/23/14, During the interview the surveyors were informed that they had not conducted the required 30-second monthly tests or an annual 90-minute test, per NFPA 101, Section 7.9.3.

1. No "30-second monthly test" Per NFPA 101, Section 7.9.3.

2. No "90-minute annual test" Per NFPA 101, Section 7.9.3.

Based on random observation during the survey walk-through, staff interview, and document review, not all emergency lighting is maintained in accordance with 7.9. These deficiencies could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

A. While accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that exterior egress paths are not illuminated by emergency lighting as required by 7.8.1.3. and 7..8.1.4. Locations observed include:
1. 1:35 PM September 23, 2014: The door from Exit Stair 4.
2. 1:40 PM September 23, 2014: The door from Exit Stair 5.

B. During a review of the facility's building systems test records, it was determined that battery-powered emergency lights are not tested for a period of 30 seconds at least once every 30 days as required by 7.9.3. During an interview held in the West Wing Seventh Floor Conference Room at 9:31 AM on September 24, 2014, the provider's Director of Support Services confirmed this finding.
C. During a review of the facility's building systems test records, it was determined that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3. During an interview held in the West Wing Seventh Floor Conference Room at 9:31 AM on September 24, 2014, the provider's Director of Support Services confirmed this finding.

Based on observations it was determined that the facility failed to provide and/or maintain the directional emergency illuminated exit signs in accordance with LSC, Section 7.10.2.

A. On 9/23/14, observations determined that the exit sign was not illuminated above the rear exit door. In the event of a fire, the exit would not be identifiable.

Based on an observation, the facility failed to install all required initiating devices to provide a "complete fire alarm system" to monitor vital equipment continuously in accordance with NFPA 101, 2000 Edition, Section 9.6 as well as NFPA 70 and NFPA 72, Section 1-5.6.

A. On 9/23/14, Center Building, 4th floor, West End, Office located in back of Nursing Station contains a smoke detector that is located within 3 ' -0 " of the supply air diffuser. NFPA 72, 1999, 2-3.5.1.


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Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

B. At 2:40 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed a smoke detector, in West Wing Fifth Floor Soiled Utility Room 512C, which is located within 3'-0" of supply air diffusers as prohibited by NFPA 72 1999 2-3.5.1.

Based on direct observation and interview, the facility failed to provide and maintain a "complete fire alarm system" in accordance with NFPA 101, 2000 Edition, Sections 4.2 and 9.6 as well as NFPA 70 and NFPA 72, Section 1-5.6. This deficient practice could affect all staff and visitors.

Findings include:

A. On 9/23/14 during interviews with facility representatives, it was determined that the smoke detectors and pull stations are not being inspected. It is unclear how the system is installed or if the system is functional.

1. lity does not maintain as-built drawings, Operation and Maintenance manuals, or operational sequence documentation per NFPA 72 1999 7-5.1.

2. Facility does not conduct periodic visual inspections of system per NFPA 72 1999 Table 7-3.1.

3. Facility does not conduct periodic tests of system components NFPA 72 1999 Table 7-3.2.

Based on fire alarm interview, the facility failed to properly test the fire alarm system in accordance with NFPA 101, 2000 Edition, Sections 4.2 and 9.6 as well as NFPA 70 and NFPA 72. This deficient practice could affect an indeterminable number of staff and visitors.

Finding include:

On 9/23/14 during interviews with facility representatives, it was determined that the smoke detectors and pull stations are not being inspected. It is unclear how the system works or if the system is functional.

A. Functional Test: Tests to be conducted on each individual smoke detector with specific information logged such as "Individual Addresses", "Manufacture's Range", "Activation Point" and "Pass/Fail".

B. Sensitivity Test: no Sensitivity Test was performed on all smoke detectors in the past 2-years. This test includes the "Manufacture's Range for each tested device.

On 9/22-23/14 observations during the walk through, the facility failed have all sprinklers installed to meet the requirements of NFPA 101, 2000 Edition, Sections 19.3.5; NFPA 13, 1999 Edition. This deficient practice would affect an indeterminable number of staff , visitors and patients, if the sprinklers failed to operate properly in the event of a fire due to improper installation.

Findings Include:

A. 7th floor Center, Surgical Suite, Nurses Lounge, the hole cut in the plaster ceiling to accommodate the sprinkler head exceeded the size of the escutcheon cap, leaving a gap of approximately ¼ " .

B. 4th floor Center, East end, North patient room toilet, the hole cut in the plaster ceiling to accommodate the sprinkler head exceeded the size of the escutcheon cap, leaving a gap of approximately ¼ " .

C. 3rd floor Center, West end, Break Room, the hole cut in the plaster ceiling to accommodate the sprinkler piping is not sealed, leaving a gap of approximately ¼ " .

D. Main floor, Center, East End, electrical closet, the hole cut in the plaster ceiling to accommodate the sprinkler head exceeded the size of the escutcheon cap, leaving a gap of approximately ¼ "

E. Main floor, Center, Medical Records, the " suite " contains a movable shelving unit with patient files. The sprinkler heads are located above the files, however since the shelves move, it is unclear if the location of the heads is adequate for this area. NFPA 13.


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Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

F. East Wing, 6th Floor: While accompanied by the provider's EVS Manager, the skylight in the Conference Room was observed that lack sprinkler coverage required by NFPA 13 1999 5-1.1.(1).

G. East Wing, 3rd Floor Radiology Department - Electrical Room / Closet between Men and Women's Gowning Room lack sprinkler protection to comply with NFPA 13 1999 5-1.1.(1).

H. East Wing, 4th Floor - a 1' x 1' hole in the gypsum ceiling was observed which compromises the activation of the sprinkler head under fire and smoke conditions and therefore does not comply with NFPA 13 1999. Location include:

1. Storage Closet in the Expressive Therapy

I. During the survey walk-through, not all portions of the facility's automatic sprinkler system are maintained in accordance with NFPA 25 1998 2-4.1.8. Sprinkler escutcheons on ceiling tiles are missing. Locations observed include:

1. East Wing, 5th Floor - Aisle in ICU Suite.

2. East Wing, 4th Floor - Aisle in Cardio/Pulmonary.

3. East Wing, 4th Floor - Expressive Therapy Room.

4. East Wing, 3rd Floor - Janitor's Closet in the Radiology Department.

5. East Wing, Ground Floor - Physical Therapy, Waiting Area.

Based on observations, it was determined that the facility failed to properly secure and inspect all portable fire extinguishers in accordance with NFPA 101, 2000 Edition 19.3.5.6, 9.7.4.1 and NFPA 10. This deficient practice could affect all Smoke Zones, and could affect an indeterminable number of patients, staff and visitors.

Findings include:

A. On 9/22/14, 7th floor, Surgical Suite, Facility staff failed to conduct all required inspections on each individual Fire Extinguisher. The last inspection of the fire extinguishers was 7/11/14. This was determined by the observation of each inspection tag located on the individual fire extinguishers provided by the facility.

Based on observations, it was determined that the facility failed to properly secure and inspect all portable fire extinguishers in accordance with NFPA 101, 2000 Edition 19.3.5.6, 9.7.4.1 and NFPA 10. This deficient practice could affect an indeterminable number of patients, staff and visitors.

Findings include:

A. On 9/23/14, Facility staff failed to conduct all required inspections on each individual Fire Extinguisher. The last inspection of the fire extinguishers was 7/11/14. This was determined by the observation of each inspection tag located on the individual fire extinguishers provided by the facility.

Based on observation and staff interview, it was determined that facility provide soiled linen or trash collection receptacles exceeding 32 gal in capacity in accordance with NFPA 101, 2000 Edition, Section 19.7.5.5. and 19.3.2.1. This deficient practice could affect an indeterminable number of staff and patients, if a fire would develop in a non-hazardous room in receptacles exceeding the maximum allowed capacity.

Findings include:

A. 7th floor Center, Surgery Suite, OR #3, contained 4 soiled linen receptacles each approximately 32 gallons and a 16 gallon trash can located within a 64 square foot area.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

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 document review and staff interview, the emergency generator is not inspected and tested in accordance with NFPA 99. These deficiencies could affect any patients, staff, or visitors in the building because the emergency generator could fail to operate under emergency conditions.

Findings include:

A. During the document review process, it was determined that the emergency generator was not visually inspected on a weekly basis, as required by NFPA 110 1999 6-4.1., between January 1, 2014 and May 31, 2014. This determination was confirmed by the provider's Director of Support Services during an interview held in the West wing Seventh Floor Conference Room at 9:41 AM September 24, 2014.

B. During the document review process, it was determined that the emergency generator storage batteries are not visually inspected on a weekly basis, as required by NFPA 99 1999 3-4.4.1.3. and NFPA 110 1999 6-3.6., between January 1, 2014 and May 31, 2014. This determination was confirmed by the provider's Director of Support Services during an interview held in the West wing Seventh Floor Conference Room at 9:41 AM September 24, 2014.

C. During the document review process, it was determined that the emergency generator is not tested under load for 30 minutes each month, as required by NFPA 99 1999 3-4.4.1.1. and NFPA 110 6-4.2., between January 1, 2014 and May 31, 2014. This determination was confirmed by the provider's Director of Support Services during an interview held in the West wing Seventh Floor Conference Room at 9:41 AM September 24, 2014.

Based on observations, the facility failed to install electrical wiring in accordance with NFPA 101, 2000 Edition, Section 9.1.2 and NFPA 70, 1999 Edition, National Electrical Code. This deficient practice could affect an indeterminable number of staff and patients that would come in contact with deficient electrical wiring.

Finding include:

A. 7th floor Center Building, Surgery Suite, does not contain normal power outlets. This does not meet with NFPA 70 (1999) 517-19.




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By direct observation and staff interview while in the company of the Facility ' s Director of Support Services and Stationary Engineer the Surveyor finds the facility does not have a compliant Type 1 Essential Electrical System. (NFPA 99, 1999, 3-4)
Observations and staff interview include but not limited to:
a. There are automatic transfer switches installed and identified for the Life Safety Branch, Critical Branch and Equipment Branch.
b. Identification of the distribution and separation for the three required branches is not provided at circuit panel locations throughout the facility.
c. Interview with the Director of Support Service and Stationary Engineer indicated that when the emergency generator is supplying electricity to the facility during a utility outage the entire facility has electrical power not just the Essential Electrical System distribution within the facility. Only those electrical loads as identified in NFPA 99, 1999, 3-4.2.2.1 shall be supported of a Type 1 Essential Electrical System.

Based on observations, the facility failed to install electrical wiring in accordance with NFPA 101, 2000 Edition, Section 9.1.2 and NFPA 70, 1999 Edition, National Electrical Code. This deficient practice could affect an indeterminable number of staff and patients that would come in contact with deficient electrical wiring.

Finding include:

A. 7th floor Center Building, Surgery Suite, an extension cord was being utilized in an OR, which is identified on the drawings as " recovery " within the Surgical Suite. This does not meet with NFPA 70 (1999) 240-4 or 305-3(b).

B. 7th floor Center Building, Surgery Suite, no battery powered emergency lights were provided in the OR ' s as required by NFPA 99, (1999), 3-3.2.1.2(a)(5)(e) and NFPA 70 (1999)517-63(a).