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Based on observation, adjacent occupancies are not continuously separated. This deficiency could affect all patients in the locations as well as any staff and visitors present, by compromising the means of egress from one occupancy to another.

The finding is:

On 06/19/2019 at 10:50am while accompanied by the CEO observation determined that the required means of egress from the South wing through the West tower, at the area northwest of the Dining area, and north of the MRI traverses is an area which is not continuously separated from healthcare by a 2-hour fire rated barrier to comply with 19.1.3.5, 19.1.3.7 or sprinkler protected to comply with 19.3.5.3, Location observed Ground floor level near Med Records West tower.

Based on observations it was determined that the facility failed to maintain the minimum Construction Type for this building. This deficient practice could compromise the fire resistant rating of the structure and affect staff and visitors in within a means of egress.

The finding is:

On 06/17/2019 at 10:45am while accompanied by the CEO, unprotected steel beams were observed. This condition does not comply with table 19.1.6.1. Location observed: South wing Mechanical Penthouse, spray on fireproofing is missing from several beams which are located within the elevator machine room and the stair leading to the elevator machine room.

Based on observation, not all doors in exit access corridors or other means of egress are available at all times for egress. This deficiency could affect all patients in the locations as well as any staff and visitors present, by compromising the direction of egress within a room or exit access corridor.

The findings are:

A. On 06/19/2019 at 9:50am while accompanied by the CEO means of egress doors were observed which lack proper egress hardware to comply with 19.2.2.2.4. Location observed: Basement (South wing) egress door from Central Supply (door #CRD #112) did not close to a latched postion.

B. On 06/18/2019 at 10:50am while accompanied by the CEO a means of egress door was observed which lacked proper egress hardware to comply with 19.2.2.2.4. Location observed: Ground floor (South wing) egress door from "Privacy Recovery Bay" to Surgery corridor lacks latching hardware.

Based on observation, not all stairs or smokeproof enclosures are constructed and maintained as required including stair components within the stair enclosure. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained.

Findings include:

A. On 06/18/2019 while accompanied by the CEO, guardrails were observed in exit stair enclosures in which the distance between rails is in excess of 4". This condition does not comply with 19.2.2.3, 7.2.2.4.5.3.

Example locations observed:
1. 10:15am Exit Stair #1(South)
2. 9:10am Exit Stair #7 (South)
3. 2:30pm Exterior Exit Stair (Ketteler)

B. On 06/18/2019 at 2:25pm while accompanied by the CEO, were observed that exterior landing for Exit Stair #1 (Ketteler)does not comply with 7.2.3 for a structurally stable exit. Surveyor observed an exterior exit stair landing which lacked structural members below the metal grating at both the top landing and intermediate landing. This condition does not comply with 7.7.3.4.

C. On 06/17/2019 at 1:45pm while accompanied by the CEO, an entry door to an exit stair was observed with non compliant field applied hardware. Location observed Stair #6 (South) 4th floor, field cut metal plate surrounding door latch.

D. On 06/17/2019 at 2:15pm while accompanied by the CEO, an entry door to an exit stair was observed which did not close to a latched position which does not comply with 7.2.2. Location observed Stair #7 (South) 5th floor.

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

The finding is:

On 06/17/2019 at 12:50pm while accompanied by the CEO, a fire barrier door was not provided with U.L. listed hardware to comply with 8.3.3, 8.3.3.2.2 and NFPA 80, 2010, 7.4.3.2 for a latching handle.
Example locations observed: South wing walkway leading to North tower on the 1st and 4th floors.

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

The finding is:

On 06/18/2019 while accompanied by the CEO Elevator lobbys were observed with one designated means of egress which leads to exit stair #7. This condition does not comply with 19.2.4.3 for two separate exits and provides a dead end corridor condition which does not comply with 19.2.5.2. Example locations observed:

1. At 3:15pm 3rd floor South wing
2. At 9:00am 6th floor South wing
3. At 2:00pm 4th floor South wing

Based on observation, not all portions of the building's Essential Electrical System (EES) are installed as required. This deficient practice could affect patients, staff, and visitors in the building because life support equipment could fail to operate under emergency conditions if the essential electrical system is not installed properly.

The findings are:

A. On 06/18/2019 at 9:20am , while accompanied by the CEO battery-powered emergency lights were observed to contain electrical cords plugged into emergency outlets. This condition does not comply with NFPA 99 2012 6.3.2.2.11.4 and NFPA 70 2011 517-63A. Locations observed: 2nd floor Surgery (South wing)


B. On 06/18/2019 at 10:20am , while accompanied by the CEO an outpatient cardio/resparatory therapy area lacked battery-powered emergency lights to comply with NFPA 99 2012 6.3.2.2.11.4 and NFPA 70 2011 517-63A. Locations observed: 2nd floor North Tower

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

The finding is:

While accompanied by the CEO, exit access was observed to not be identified by exit signage. This condition does not comply with 19.2.5, 39.2.5.2 and 7.5. Example locations observed:

1. On 06/18/2019 at 11:25am 3rd floor corridor located between the South wing and the North tower.
2. On 06/18/2019 at 12:45pm 1st floor surgery corridor adjacent to OR #6 and #7.

Based upon observation, vertical openings are not constructed and maintained to provide separation of floor levels in accordance with requirements. Failure to protect vertical openings can permit the effects of a fire/smoke event to expose and compromise the safety of occupants utilizing an exit stair.

The findings include:

A. On 06/17/2019 at 2:35pm while accompanied by the CEO a pipe chase was observed to not be completely enclosed with a minimum 2-hour fire rated construction to comply with 8.3.5.1, 8.3.5.7, and 9.2.1. Location observed: North Wing, 4th floor, room #4915A, conditions observed:

1. recessed metal floor pan used for infill does not maintain the 2-hour fire resistance rating.
2. masonry walls contain holes within the fire bricks.
3. A large 2' by 2' hole is present in the wall shared with the conference room

B. On 06/19/2019 at 10:10am while accompanied by the CEO, the surveyor was informed that a linen chute was no longer used. The linen chute was not permanently disabled so as to remain out of use to comply with 19.3.1. Location observed: Basement level, West tower, the Environmental Services Chute room

Based upon observation, non-sprinklered hazardous areas are not separated by a minimum of fire resistant construction. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

The finding is:

A. On 06/18/2019 at 2:45pm while accompanied by the CEO the Ground floor kitchen was observed (which lacks sprinkler protection) to not be separated from the remainder of the sprinkler protected building in order to comply with 39.3.2.1, 8.7.1.1(1), 8.3.1.2(1) and 8.3.3.3 due to the following:

1. Not all doors leading from the kitchen are a minimum 3/4 hour rated doors to comply with 8.3.4.2.
2. Not all doors leading from the kitchen are self closing to comply with 8.3.3.3 and 7.2.1.8.
3. Not all doors leading from the kitchen close to a latched position to comply with NFPA 80, 2010

Based on observation fire pull stations are not properly located. This could affect patients, staff and visitors of the areas served if the fire alarm system does not operate properly during a fire emergency.

The finding is:

A. On 06/19/2017 at 10:30am while in the company of the CEO,a manual pull station was not located within 5 feet of the designated exit door to comply with NFPA 72-2010, 17.14.6. Location observed: Basement (West wing) Stair #5 has a pull station greater than 15 feet from the exit.

Based on observation, not all portions of the building's fire alarm system are installed and maintained as required. This deficient practice could affect patients, staff, or visitors in the building because the fire alarm system could fail to activate under emergency conditions if the components are not properly installed and maintained.

The finding is:

B. On 06/19/2019 at 11:25am while accompanied by the CEO, single station smoke alarms and audible devices were not provided to comply with NFPA 72-2010, 18.5.6.4. Location observed: South wing staff sleeping rooms.


C. On 06/19/2019 at 10:52am while accompanied by the CEO observation determined that unsupervised waiting areas not separated from the corridor lack smoke detection to comply with 19.3.4 and 19.3.6.1.
Location observed; Ground floor, West tower, at the area northwest of the Dining area, and north of the MRI and Medical Records

Based on observation, sprinklers are not provided in all spaces to comply as a fully sprinklered building. Failure to install and maintain a fully sprinklered building could compromise the suppression of a fire affecting all occupants of the building in case of fire event.

The findings include:

A. On 06\19\2019 at 8:45am while accompanied by the DFPO-SO a suspended acoutical tile soffit was observed with large holes and missing tiles which permits a civity for smoke accumulation thereby delaying sprinkler response times. This condition does not comply with NFPA 13-2011, 8.6.4.1. Location observed: Basement (West tower) between Mechanical and EVS Storage.

B. On 06/19/2019 at 9:15am while accompanied by the DFPO-SO, a "vestibule" area located directly below an exit stair run was observed which lacked sprinkler protection. This "vestibule" area led to an IT room. This condition does not comply with NFPA 13 2011 8.3. Location observed: Ground floor, Exit Stair #2,

C. On 06/19/2019 at 9:20am while accompanied by the DFPO-SO, an IT room was observed which was not fully sprinkler protected which does not comply with NFPA 13 8.3. Location observed: Ground floor, Access from Exit Stair #2.

D. On 06/18/2019 at 9:45am while accompanied by the DFPO-SO, an alcove with a folding wood door was observed to be used for linen storage and was not covered by a sprinkler head.
Location observed: South wing 2nd floor

Based on observation, the facility failed to provide access to fire protection appliances within the ventilation duct system. Failure to install and maintain this installation could result in the passage of fire and products of combustion from one fire compartment to another. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 06/18/2019 at 11:30am accompanied by the CEO observation determined that an access door to be located at a duct penetrating a 2-hour fire barrier could not be located. Therefore the inability to access dampers for inspection and maintenance does not comply with NFPA 80-2010, 19.2.3.
Location observed: 3rd floor 2-hour barrier between North and West towers adjacent to room #W3395 (utility room with chutes).

Based on observation, the medical gas piping system is not maintained in compliance with NFPA 99. The deficient practice could affect patients, staff and visitors if not providing direct access to system components which would prevent staff form these services.

The finding is:

On 06/18/2019 at 1:06pm, while accompanied by the CEO observation determined a linen cart and med supply cart were parked in front of a med gas zone valve and a med gas alarm panel. This condition does not comply with NFPA 99 2012, 5.1.4.8.4 and 5.1.4.8.5.

Location observed: 1st floor Surgery sub sterile between OR #1 and OR #2.

Based on observation during the survey walk through the facility failed to install a compliant emergency electrical system. Failure to install and maintain these systems could result in delayed response. This deficient practice could affect patients, staff and visitors during a utility power outage.

The findings are:

A. On 6/19/19 at 9:00am accompanied by the CEO it was observed that connection of the battery chargers for both emergency generators were connected at the battery end of the starting cables and not to the primary side of the starter solenoid (positive) and the EPS frame (negative). NFPA 110, 2010, 7.12.6.2


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B. On 06/17/2019 at 8:45am while in the company of the CEO, It was unknown which branch of the essential electrical system serves the isolation panels provided for each O.R. This condition was observed within the substerile rooms located between each O.R. Due to this condition it is unknown which branch of the essential electrical system provides power to the isolation panels which provide power to the emergency outlets within each O.R (South). The condition does not comply with NFPA 70-2011, 408.4.

Based upon direct observation during the survey walk-thru, electrical systems are not maintained in conformance with Code requirements. Failure to maintain the electrical system can lead to confusion when selected components require shut-down for maintenance and power circuits cannot be accurately identified.

The finding is:

On 06/17/2019 at 9:45am while in the company of the CEO, it was observed that a critical care patient room contained emergency outlets which did not identify the electrical panel which served them. This condition was observed within all critical care patient areas. Example locations observed: CCU (South), Surgery (South), ICU(South). The condition does not comply with NFPA 70-2011, 408.4 due to the following:

1. The emergency outlets do not indicate the electrical panel which serves them.

2. It is unknown which branch of the essential electrical system (EES) each emergency panel is fed from (Life Safety, Critical or Equipment)

3. It is unknown which automatic transfer switch from the EES powers which electrical panel.

Based upon observation, the facility failed to provide properly ventilated hazardous areas for medical gas storage. The condition of oxidizing gas in a confined area, may lead to an acceleration of a fire event. This deficient practice could affect patients, staff and visitors in the area.

The finding is:

On 06/18/2019 accompanied by the CEO, medical gas "E" sized tanks (approximately 25 c.f.) are allowed to be stored less than five feet from combustibles which does not comply with 19.3.2.4, 8.7.1.1(1), NFPA 99 2012, 5.1.3..2.
Example locations observed:

1. At 1:30pm South wing, 5th floor respiratory storage located across from room #525
2. At 2:50pm South wing, 6th floor - storage room #647