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Based on random observation during the survey walk-through while accompanied by engineering staff, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

A. On the morning of 05/08/13, Building - 01, Second Floor: Portions of the structural steel beam, deck and a column were observed to be missing fire proofing materials in accordance with the designated UL Design. Locations observed include:

1. Above the ceiling panels of the Auditorium near the double entrance doors.

2. Exit access corridor leading to the Stair 13A and by the exit stair doors.


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B. On 05/08/13 at 11:00 am, Day Surgery, Nourishment room #1R-29 (from facility Life Safety plan dated 2/22/13) unprotected steel beam flanges were observed at the south and and east walls, which do not maintain the building's designated construction type.

Based on observation during the survey walk-through, not all interior finishes for corridors comply with applicable requirements of the Life Safety Code. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, because the lack of compliance can expose occupants to harmful fire and smoke conditions.

Findings include:

A. (Modified 11/01/13): At 1:45 pm on 5/8/13 the Main Lobby was observed to have wood panel wall finishes on multiple walls. Further, the surveyor observes that this material has been painted. The provider lacks specific documentation for the material and the finish which demonstrate that these walls comply with NFPA 101-2000, 19.3.3.2 as minimum Class B Interior Finish.

Based on observation during the survey walk-through, not all interior finishes of rooms comply with applicable requirements of the Life Safety Code. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, because the lack of compliance can expose occupants to harmful fire and smoke conditions.

Findings include:

A. At 10:45am on 5/8/13 the Cafeteria Dining room on the 2nd floor was observed to have a wood slat ceiling system which could not be documented by staff at the time of the survey to meet the minimum finish rating requirements of NFPA 101-2000, 13.3.3 for an existing Assembly occupancy. The provider is not able to demonstrate that the above ceiling provides at least a Class C Finish if the occupant load is less than 300 or a Class B Finish if the occupant load is greater than 300.

11/01/13: The provider has written documentation for an intumescent coating which they believe was used on the above referenced ceiling but lacks written documentation including when and who, which indicates that the coating was used on the ceiling.

B. Corrected 11/01/13

C. (New 11/01/13) Basement Mezzanine Level Engineering spaces: Although the paneling in the old blueprint room was removed, other spaces on the same level (including the conference room A-351, A-354 and a glass wall receptionist space) was observed to have wood paneling walls that could not be documented to meet the Class C minimum finish rating requirements of NFPA 101-2000, 39.3.3.2.

Based on observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the locations, as well as any staff and visitors present, because the lack of smoke detectors leaves the exit access corridors unprotected against early and prompt notification of a fire event that could render the exit access corridors unusable.

Findings include:

A. Corrected 11/01/13

B. Corrected 10/31/13


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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect any building occupants in the exit access corridors adjacent to the rooms listed, because smoke and fire could pass from them into the corridors.

Findings include:

C. Deleted 10/31/13; area under construction and not part of a means of egress.

D. Modified 11/01/13: Building - 01. The First Floor Lab/Radiology Reception and Waiting Area is greater than 600 square feet and was observed to be open to and not separated from the exit access corridor. This space is not supervised 24/7 and therefore lacks smoke detection installed to protect the entire space (spacing per NFPA 72) to comply with 19.3.6.1. Exception 6.

Based on observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. Corrected 10/31/13

B. At 10:05am on 5/8/13 it was observed that corridor doors to 4th floor rooms 401, 402 & 403 were equipped with push/pull hardware in combination with deadbolt locks operated with key only from the corridor side. The hardware does not provide latching to comply with 19.3.6.3.2 and the deadbolt lock can prevent egress in noncompliance with 19.2.2.2.2. The rooms were not equipped to provide direct observation of a patient if considered to be used for seclusion.

11/01/13: What are the specific interim life safety measures proposed until the above item is corrected?

C. During the survey walk-through, Janitor closets observed to be storing combustible materials were equipped with corridor doors containing louvers in noncompliance with 19.3.6.4 Exception. Locations observed include:

1. At 2:00pm on 5/7/13 6th floor Janitor
Closet 633-A used to store paper
supplies.

2. Corrected 10/31/13

3. Corrected 10/31/13


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Based on random observation during the survey walk-through and staff interview, not all doors in exit access corridors are in compliance with 19.3.6.3. This condition could affect patients, visitors and staff within an exit access corridor during a fire condition.

Findings include:

D. Doors in exit access corridor doors were observed with a transfer grille that is not resistive to the passage of smoke as required by 19.3.6.4. Locations observed include:

1. Morning of 05/07/13, Building -01,
Tenth Floor, Med/Surg Unit: Storage
Room 1033A.

2. Afternoon of 05/07/13, Building -01,
Ninth Floor, Med/Surg Unit: Storage
Room 933A.

11/01/13: What are the specific interim life safety measures proposed until the above two items are corrected?



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Based on random observation while accompanied by engineering staff, corridor doors are not always positive latching in accordance with 19.3.6.3.2 and/or that corridor doors are not installed to maintain a smoke tight condition. Failure to maintain corridor doors in accordance with NFPA 101 could allow smoke to spread from room to room in a fire emergency.

Findings include:

E. 05/08/13 at 2:35 pm, 1st floor corridor doors are provided with a push/pull with deadbolt hardware. These corridor doors do not comply with 19.3.6.3.2 for providing positive latching hardware. Example locations observed:

1. Cystology
2. Stage I Recovery
3. Endoscopy

F. 05/08/13 at 2:55 pm, 1st floor means of egress corridor doors from the ICU contain a pair of pocket doors with motion detection and a swing door with a hold open device within the same framed opening.

1. Corrected 11/01/13

2. Corrected 11/01/13

3. Corrected 11/01/13

4. Corrected 11/01/13

5. New 11/01/13: Two pairs of pocket
sliding doors break and swing into the
corridor but do not swing 180 degrees.
They obstruct the exit access corridor
by more than 7" when fully open.
(7.2.4.4)

Based on observation during the survey walk-through, not all vertical openings are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels.

Findings include:

A. At 10:55am on 5/7/13 it was observed at the 8th floor Communications closet 833B that miscellaneous through-floor conduit (sleeves for wiring) were not sealed to maintain the floor barrier rating against fire and smoke to comply with 8.2.3.2.4.2.

B. At 11:05am on 5/7/13 it was observed that the fire rated access door to the shaft accessed from the 8th floor Janitor closet located within the Eye Clinic File room lacked a latch strike to provide a complete rated door assembly to comply with NFPA 80.

C. At 11:30am on 5/7/13 it was observed that the fire rated access door to the shaft accessed from the 8th floor Janitor closet 815A lacked a latch strike to provide a complete rated door assembly to comply with NFPA 80.

D. At 1:15pm on 5/7/13 it was observed that the fire rated access door to the shaft accessed from the 7th floor old Janitor closet 733A lacked a latching door and a strike to provide a complete rated door assembly to comply with NFPA 80.


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Based on random observation during the survey walk-through, not all shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect any patients, as well as any staff and visitors becaues the failure to provide self-closing doors and proper installation of shaft could result in smoke or fire passing from one part of the building to another.

Findings include:

E. Morning of 05/9/2013, Building - 01, Tenth Floor, The door to a shaft (dumbwaiter) located inside the Soiled Utility Room did not self-close all the way to positively latched as required by 8.2.3.2.1.


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Based on random observation during the survey walk through while accompanied by engineering staff, 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. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke and fire to pass between building stories.

Findings include:

F. 05/07/13 at 10:30 am, a series of pipe penetrations through the 2 hour fire rated floor assembly, in an 11th floor Electrical Closet (#1121 A) were observed to not be sealed against the passage of fire/smoke to comply with 8.2.3.2.4.2.

G. 05/08/13 at 2:30 pm, a duct was observed above the ceiling of the 12th floor at the intersection of corridor 1236 D and 1201 G (as shown on the facility provided Life Safety plan dated 2/22/13), which penetrates the floor of the Penthouse above (near Passage P 014-as shown on the facility Life Safety plans dated 2/22/13). This penetration lacks the installation of a fire damper within the plane of the floor to comply with NFPA 90 A 1999 3-3.2.

Based on observation during the survey walk-through, not all doors required to be self-closing are in compliance with 7.2.1.8.1. This deficiency could affect all persons within the smoke compartment by allowing the products of combustion to pass from one side of the door to the other; either compromising the building's exit access corridors or the rooms occupied or adjacent to the space designed to be separated.

Finding include:

A. At 2:45pm on 5/6/13 it was observed that the Penthouse P107 Mechanical room door was propped open with a concrete block in noncompliance with 39.3.2.1, 8.4.1.2, 8.2.4.3.5 and 7.2.1.8.1. This room was also considered to be part of a shaft due to the inability to locate access to fire dampers at the ducts entering the adjacent shaft(s). The door to this room was not labeled to comply with 8.2.3.2.1.

B. At 11:00am on 5/7/13 it was observed that the 8th floor Eye Clinic file room door was being held open with a wood wedge in noncompliance with 8.4.1.2, 8.2.4.3.5 and 7.2.1.8.1.


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C. On the morning of 05/08/13, Building - 01, First Floor - Family Health Center (FHC) Billing Office is also being used for storing Medical Records Files and the door to this room is pegged with un-approved hold-open device to comply with 8.4.1.2, 8.2.4.3.5 and 7.2.1.8.1.

Based on random observation during the survey walk-through while accompanied by engineering staff, 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. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

The finding is:

A. Designated 2 hour fire rated existing and smoke barrier walls on the Life Safety Plan were observed to contain penetrations like conduits that are not fire sealed. Location observed include:

1. On the morning 05/08/13, Building - 01, First Floor: Radiology above the ceiling of double doors near the Locker Room 1-665.


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B. On 05/07813, at 10:45 am,1st floor smoke barrier within the Day Surgery area at the east wall of the Nourishment room contains multiple holes along with pipe and conduit penetrations that are not sealed against the passage of smoke to comply with 19.3.7.3. and 8.3.2.

Based on random observation during the survey walk-through, while accompanied by engineering staff, not all designated or required smoke barrier doors are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

The finding is:

A. 05/09/13 at 1:45 pm, 10 th floor pairs of cross corridor doors located in the West corridor failed to close to a smoke tight position. This condition was discovered during the testing of the fire alarm system. One door contains an extended bolt throw which did not allow the other door to close completely to comply with 7.2.1.8.2.

11/01/13: What are the specific interim life safety measures proposed until the above item is corrected?

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with NFPA 101-2000, 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. Corrected 11/01/13

B. At 2:35pm on 5/6/13 it was observed that the door to Storage room P100 at the Penthouse level was not self-closing and contained an operable louver in non-compliance with 8.2.4.3.3 and 8.2.4.3.5.

C. Corrected 11/01/13

D. Corrected 11/01/13

E. At 9:30am on 5/8/13 it was observed that the 4th floor Mechanical/storage room 448 corridor door was not self-closing to a latched condition. This room is designated as 2-hour enclosed. Two sets of pairs of doors to this room are equipped with knob hardware on both leafs of the doors where the active leaf is also equipped with an astragal. The arrangement does not comply with 7.2.1.5.5 because the inactive leaf can be mistaken as an active leaf and cannot be opened without first opening the active leaf. Stored material obstructed the swing of the active leaf at the north door to the Mechanical room. The south door to the mechanical room had both a slide bolt and a knob set on the inactive leaf.

F. (Modified 11/01/13): At 10:45am on 5/8/13 it was observed that the exit corridor west of the 2nd floor kitchen outside the entrance to Stair #5 was being utilized for the storage of carts, wheeled waste bins, and equipment related to the kitchen in noncompliance with 7.5.1.7 and 8.4.1. Surveyor notes that exit signage from the adjacent corridor is directed into this service corridor utilized for storage which makes it a required exit access corridor.

Also the pair of doors to the Kitchen from this corridor lack positive latching hardware.

G. At 11:00am on 5/8/13 it was observed that the 2nd floor kitchen storage rooms 240B & 240C lack self-closing doors to comply with 8.4.1.2 and 8.2.4.3.5.

H. At 2:30pm on 5/8/13 it was observed that the 1st floor Physical Therapy storage room 14-91A lacks a self-closing door to comply with 8.4.1.2 and 8.2.4.3.5.

I. At 2:40pm on 5/8/13 it was observed that the 1st floor file storage/workroom 1-484B lacks two self-closing doors to comply with 8.4.1.2 and 8.2.4.3.5.

J. At 2:41pm on 5/8/13 it was observed that the 1st floor storage room 1-498 lacks a self-closing door to comply with 8.4.1.2 and 8.2.4.3.5.

K. At 11:00am on 5/9/13 it was observed that the hydraulic elevator equipment room A364 door was not self-closing and fire rated to comply with 8.4.1.1(3). (The equipment room is considered a severe hazard relative to the quantity of hydraulic fluid.)


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L. On the Morning of 05/07/13, Building -01, Tenth Floor - Med/Surg Unit: An electrical conduit located above the north east door to the Soiled Utility Room penetrates the wall that is not sealed against fire to comply with 8.2.3.2.4.2.

M. On the afternoon of 05/07/13, Building - 01, 9th Floor - Med/Surg Unit: The Clean Holding which is a designated one hour enclosure room was observed with a conduit penetration above the NW door that is not fire sealed to comply with 8.2.3.2.4.2.

N. On the afternoon of 05/07/13, Building - 01, 9th Floor - Med/Surg Unit: Identified 920A Exam Room which is less than 100 sq. ft. is being used for storage, the door to this room is not self-closing to comply with 8.2.3.2.3.1(2).

O. On the afternoon of 05/07/13, Building - 01, 9th Floor - Med/Surg Unit: The Soiled Holding noted to be separated by two hour construction was observed with conduit penetrations (3) that are not fire sealed to comply with 8.2.3.2.4.2 and 19.3.2.1.

P. On the morning of 05/08/13, Building - 01, 2nd Floor - Auditorium: The double doors to the Storage Room are required to be self-closing but one of the leafs was broken.

Q. On the afternoon of 05/08/13, Building - 01, First Floor - The Family Health Center (FHC) Billing Office is also being used for storing Medical Records Files and was observed with a pipe and a conduit penetrations that are not sealed against the passage of smoke.


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Based on random observation during the survey walk-through while accompanied by engineering staff, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor during a fire emergency.

Findings include:

R. 05/08/13 at 1:15 pm, various rooms which do not meet the minimum requirements for hazardous areas are being used as storage rooms and deemed hazardous due to the amount of combustible materials, boxes, files, equipment and furniture. These rooms/areas do not comply with 19.3.2.1 for protection of hazardous areas due to the following:

1. Day Surgery designated 1 R-11 Waiting
room (located south of the 1 R-22
Vestibule Center) is being used as storage
and does not comply with 19.3.2.1 due to
the following:

i. The sprinkler system does not provide
adequate coverage due to openings
within finished ceilings along with
missing ceiling tiles in suspended
acoustical ceiling systems. For example:
Men's and Women's toilet areas, and
vending area.

ii. The perimeter walls are not smoke tight
due to numerous holes and unsealed
penetrations.

iii. The entry doors are not self closing. For
example, the doors leading to Doctor
Offices.

2. Day Surgery 1 R-22 Vestibule Center adjacent to the nurses station contains
numerous gurneys stored within the means
of egress.

3. 1st floor, ICU patient isolation room is
being used as storage and does not comply
with 19.3.2.1 for smoke tight perimeter
walls, self closing and latching door.

S. 05/07/13 at 10:05 am Third floor janitor closet located within the Delivery corridor, contains large holes in the wall behind the mop sink which does not allow a smoke tight enclosure.

T. 05/08/13 at 10:15 am Third floor Equipment storage room #3-303-referred to as Clean Holding by facility staff (per life safety floor plans) contains an entry door with a hold open device which does not comply with 19.3.2.1 and 7.2.1.8.1.

U. 05/08/13 at 2:15 pm 1st floor Surgery Sterile Core contains numerous shelves and material storage and it is not designated as a hazardous area to comply with 8.4.1. It does not have perimeter smoke tight walls with doors with a means for maintaining a closed position to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

A. 11/01/13: After reviewing the currently cited deficiencies in the field and the current PoC for K033, K034 and K038, the surveyor finds that the provider lacks an exit study by floor which clearly identifies the exits for each floor and an evaluation of each exit for compliance with 7.7.1 and 7.7.2, based on the requirements for each floor.

B. Multiple floor plans available onsite identify the use of horizontal exits on multiple floors. Based on previous submittals, the surveyor observes that some of these horizontal exits are required exits. However, the fire barriers which define these designated horizontal exits are not shown continuously from foundation to roof in accordance with 7.2.4.3.1 (NFPA 101). Accordingly, under 7.2.4.3.1 (c) all exits must discharge directly to the outside and most or all of the required exit stairs may not use 7.7.2 for compliance (see "A" above).


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Based on observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 2:30pm on 5/6/13 it was observed that the fire rating labels on the stair doors of the Penthouse level were painted which did not allow confirmation of the opening protection required by NFPA 101-2000, 8.2.3.2.1. Painted fire protection rated labels for other doors to storage rooms, mechanical spaces, and shafts were also noted on this floor.

11/01/13: The surveyor observed that the labels are still painted. The surveyor finds that the 2015 proposed date of correction for the above item is not reasonable.

B. At 11:15am on 5/7/13 it was observed that conduit penetrations above the east door of Stair #4 on the 8th floor were not sealed to comply with NFPA 101-2000, 8.2.3.2.4.2.

C. At 1:00pm on 5/7/13 it was observed that the enclosure wall at Stair #4 on the 7th floor above the east door 703B was incomplete in non-compliance with NFPA 101-2000, 8.2.3.1.

D. At 9:30am on 5/9/13 it was observed that the exit passageway serving as the discharge for Stair #4 leads through Stair #14A.

1. Stair 14A contains elevator openings
(do not comply with 9.4.7) and has the
elevator machine room (considered a
normally unoccupied space) accessing
the stair in noncompliance with
7.1.3.2.1(d). Stair #13A also has these
conditions.

2. The exit passageway does not terminate
directly at a public way or at an exterior
exit discharge to comply with 7.7.1 and
7.1.3.2.2 (without going through Stair
14A).

3. (Modified 11/01/13): The exit
passageway contains recessed medical
gas zone valves in the enclosing walls.
The provider lacks information which
demonstrates how fire rating for the
walls are maintained at these zone valve
boxes. This is not a deficiency if this
space is not an exit passageway.

4. The exit passageway has openings onto
it from normally unoccupied spaces
such as the Cath Lab storage rooms and
telecom/electrical rooms in
noncompliance with 7.1.3.2.1(d).



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Based on random observation, the surveyor find that required exit stair enclosures do not provide a continuous path of escape and do not provide protection against fire or smoke from other parts of the building to comply with Chapter 7. These deficiencies could affect any patients from this building and as well as any staff and visitors because designated exit stairs are not protected against fire or smoke conditions to comply with 8.2.5.2.

Findings include:

E. On the afternoon 05/09/13, Building - 01, Basement Level: Exit Stair #13A was observed with stored construction materials like gypsum boards located behind the Elevator #13.

F. On the afternoon 05/09/13, Building - 01, Basement Level: Identified Stairwell 2A B-326A discharges into the First Floor near the Main Lobby, surveyor observed that one leaf of the pair of doors on the First Floor level does not latch upon closing to comply with 8.2.5.2.


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Based on random observation during the survey walk through, while accompanied by engineering staff, not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This condition may affect patients, staff and visitors on the upper floors from a safe means of egress during a fire/smoke event.

G. 05/07/13, at 11:15 am The Life Safety plans indicate that Stair # 3 and Stair # 9 are both served by a 2-hour fire rated exit passageway on the 1st floor (North side). The exit passageway does not comply with 19.3.1.1 due to the following:

1. A Storage room opens into the exit
passageway which does not comply
with 7.1.3.2.1 (d) which limits openings
into an exit passageway for those
necessary for access from occupied
spaces.

2. A pair of fire rated entry doors from the
Surgery area did not close to latch under
fire alarm conditions.

Based on observation during the survey walk-through, not all exit stairs are constructed in accordance with the requirements of 19.2.2.3 & 7.2.2. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by impeding the use of the stairs during building exiting.

Findings include:

A. On the morning of 5/9/13 it was observed that stair enclosures were being used as storage stations for housekeeping equipment/misc supplies in noncompliance with 7.1.3.2.3. Observations include:

1. At 9:50 am a trash cart was observed at
the 1st floor level of Stair #4 1-162.

2. At 10:30am a trash receptacle was
observed at the landing of Stair #8.

3. At 10:35am a snow-melt spreader and
bags of snow-melt were observed to be
stored at the top landing of Stair #7.

4. At 10:45am a housekeeping cart was
observed within Stair #10 at the
Basement level.

11/01/13: The PoC does not include a correction date for the above items and does not indicate that immediate correction is proposed.

B. Facility Stairs serving five or more stories are not provided with stair identification signage in accordance with NFPA 101-2000, 7.2.2.5.4. Surveyor was unable to locate signage within the stair enclosures at each landing that identifies the story, the top and bottom terminus, and the identification of the stair enclosure. Stairs serving five or more stories include #3, #4, #5, #6.

11/01/13: The PoC does not include a correction date for the above items and does not include the use of temporary signage as an interim measure until the item is corrected.

C. Facility Stairs serving four stories or more did not comply with the provisions of 7.2.1.5.2 to allow re-entry from the stair enclosures to the building interior. Not all levels were unlocked for re-entry; unlocked during fire alarm activation; or otherwise compliant with all provisions of Exception No. 1 to 7.2.1.5.2. Stairs serving five or more stories include #3, #4, #5, #6.

11/01/13: The items remain uncorrected. The PoC does not include a correction date for the above items and does not include the use of temporary signage as an interim measure until the item is corrected.

A. In spite of the deficiencies cited on the previous survey relative to the use of pad locks, on 10/31/13, the surveyor observed and 8th Floor patient wing where the wing was vacant and all of the patient rooms doors had padlocks installed to prevent the doors from being opened (example: 804A and 805). This condition does not comply with 7.2.1.5. The locks cannot be release from inside the room at all and immediate correction was required. The provider lacks adequate interim life safety measures to prevent re-occurrence.

B. (New 11/01/13): From direct observation, the surveyor finds that there is an identified exit path from the 2nd Floor Cafeteria, through the Doctor's Dining Room to Exit Stair # 3:

1) The exit path is then through a small space marked as a corridor on plans immediately adjacent to Exit Stair # 3. This space is a vestibule rather than a corridor. Two doors from the adjacent Kitchen open into this vestibule. The doors have U L Labels as 90 minute fire doors. The doors have magnetic hold open devices but lack smoke detection in accordance with 7.2.1.8 an 19.2.2.2.6

2) The Kitchen doors have slide bolts in addition to latching hardware. The slide bolts do not comply with 7.2.1.5 and/or ADA.

3) A large gray kitchen cart in the above space prevents one of the two doors from closing


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Based on observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets; are provided with dead bolt locks operated only by a key from either side; or are provided with locking hardware which can prevent egress. The dead bolt lock constitutes a second releasing operation to operate the the door when used in combination with latching hardware in noncompliance with 7.2.1.5.4. The key-only dead bolt locks are not operable for exiting without a key in noncompliance with 7.1.10.1. Padlocks, hasps and slidebolts can either prevent egress or constitute a second releasing operation. Locations observed include but are not necessarily limited to the following:

1. At 1:20pm on 5/7/13 the 6th floor Men's & Women's toilet room doors
were observed to have both thumbturn
deadbolts and privacy locksets in
noncompliance with 7.2.1.5.4.

2. At 2:10pm on 5/7/13 the 6th floor On
call rooms were observed to have both
deadbolt locks and combination locksets
in noncompliance with 7.2.1.5.4.

3. At 2:15pm on 5/7/13 the 6th floor
Anesthesia/Cardiology On-call room
622 was observed to have a deadbolt
lock, a latchset and a slidebolt lock in
noncompliance with 7.2.1.5.4.

4. At 3:00pm on 5/7/13 the 4th floor
Activity rooms 410, 427 &440 were
observed to have corridor doors to the
rooms equipped with deadbolt locks
and latchsets in noncompliance with
7.2.1.5.4.

5. Deleted 11/01/13

6. Deleted 11/01/13

7. At 9:45am on 5/8/13 the 4th floor
patient rooms were observed to have
corridor doors with deadbolt locks key
operated only from the corridor side
which can prevent egress from the
room in noncompliance with
19.2.2.2.2. The rooms were not
equipped to be provided with visual
observation by staff to permit use as
seclusion rooms. Some doors also have
multiple mortise latches which appear
to be operational. If both latchsets are
operational, the installation does not
comply with 7.2.1.5.4. If only one
latchset is operational, the presence of
two sets of hardware could confuse
occupants when selecting the intended
operational hardware set.

8. At 10:45am on 5/8/13 it was observed
that the 2nd floor Kitchen Dishwashing
room and the Kitchen have marked exit
path doors with panic hardware that
also have slide bolt locks in
noncompliance with 7.2.1.5.4 and
7.2.1.5.6.

11/01/13: The PoC does not indicate
that the slide bolts will be removed
immediately.

9. At 10:50am on 5/8/13 it was observed
that the 2nd floor Kitchen dry storage
room door was equipped with a
deadbolt lock keyed from one side only.

11/01/13: The PoC does not indicate
that a thumbturn will be installed
immediately.

10. At 11:30am on 5/8/13 it was observed
that the 2nd floor Volunteers office
door was equipped with a combination
lock and a knobset. The door could not
be opened to verify that the door could
be operated with a single releasing
operation to comply with 7.2.1.5.4.

11. At 1:30pm on 5/8/13 it was observed
that the corridor door from the 1st floor
Elevator #9 lobby was equipped with a
deadbolt lock and latching hardware.

12. At 2:30pm on 5/8/13 it was observed
that the corridor door at the 1st floor
Physical Therapy dept. was equipped
with a deadbolt lock and latching
hardware.

13. At 10:30am on 5/9/13 it was observed
that two of three doors at the exterior
discharge of Stair #7 were not able to be
opened.

11/01/13: Immediate correction of the
above item is not identified in the PoC.

14. At 11:15am on 5/9/13 it was observed
that the Basement level materials
management storage area caged records
area was provided with a padlock at the
single available entry/exit point of the
caged area. Although a door to the
adjacent laundry area exists, it was not
available for use because shelving units
had been placed in front of it to make it
unusable.

15. At 10:45am on 5/9/13 it was observed
that numerous rooms at the Basement
level OB/GYN training rooms (old
cobalt treatment area) were equipped
with hasps and padlocks and deadbolt
locks which can prevent egress from
the rooms.

11/01/13: The PoC does not identify immediate removal of all hasps and padlocks and also removal of all deadbolts which do not at least have thumbturns inside.



16339

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

B. Doors in exit access corridors were observed that are equipped with thumbturn
deadbolt retractor, which require more than one releasing mechanism operation toexit
the room as prohibited by 7.2.1.5.4. These deficiencies could affect patients receiving treatment, as well as any staff and visitors present, by preventing them from exiting the building under emergency conditions. Locations observed include:

1. Building - 01, 5th Floor: Dizziness Center Room 522.

2. Deleted 11/01/13

3. Building - 01, 5th Floor: EMG Patient Room 520.

4. Building - 01, 5th Floor: Wash Room across Staff Corridor 529.

5. Building - 01, 5th Floor: Doors (two) to Physical Therapy Unit.

6. Building - 01, First Floor (Radiology Unit): Radiology Room I, Rad Room 2, CT Scan 3, Rad Room 5, Room 6.

7. Building - 01, First Floor (Radiology Unit): CT Scanner 2 and Room 1-658.

8. Building - 01, First Floor, Family Health Center ( FHC): The corridor door (Door 1-370) to the FHC on the north east aisle of the D &T Staff Area.


20224


Based on random observation during the survey walk-through while accompanied by engineering staff, exit access was not readily accessible at all times in accordance with 7.1 and 19.2.1. 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 utilizing an available exit from the building during an event requiring such exiting.

Findings include:

C. Deleted 10/31/13

D. Deleted 10/31/13 - see K018

E. 05/08/13 10:15 am, 3rd floor LDR wing, Stair #5 and Stair #6 both contain magnetic locking devices and alarms. These doors do have a delayed egress device. However, the doors do not comply with 7.2.1.6.1 for identification signage.

11/01/13: The above item has a 2015 correction date; interim measures are not included for this item which provide temporary signs until correction is completed.

Based upon observation during the survey walk-through, not all exit access doors provide a minimum 32" clear width to comply with 19.2.3.5. Locations observed include:

Findings include:

A. At 9:30am on 5/9/13 it was observed that the 1st floor level pair of doors leading to the southeast glass enclosed stair through the 2-hour rated wall were provided with a center mullion which reduced the clear width of each door leaf opening to less than 32".


16339

Based from observation exit access doors used by healthcare occupants are not meeting the 32" minimum door width requirements to comply with 19.2.3.5. These deficiencies could affect all patients in the Family Health Center by preventing occupants from immediately reaching an exit from the building because the minimum exit access door width is not met.

Findings include:

B. Afternoon of 05/08/13, Building - 01, First Floor - Family Health Center (FHC): During the survey walk-through and staff interview, it was determined that the FHC Suite is being used for outpatients and for ED patients. The surveyor observed egress doors to Examination Rooms to be 24" in width which are less than the minimum width requirements of 19.2.3.5.

From random observation during the survey walk-through while accompanied by the Facilities Representative not all designated suites comply with 19.2.5 concerning the remotely located exit access doors. This condition may affect patients, staff and visitors during a fire emergency by increasing the amount of time and travel distance required to reach an exit access corridor.

Findings include:

A. (Modified 11/01/13): 05/08/13 at 2:50 1st floor ICU was identified as a suite of approximately 4,500 square feet with two means of egress, which are both located on the West corridor wall, and do not comply with 19.2.5.2 and 7.5.1.4 for the minimum distance required (remoteness) between means of egress doors from this space.


B. 05/07/13 at 2:50 1st floor Surgery was identified as a suite of approximately 6,900 square feet with one means of egress from the sterile core which does not comply with 19.2.6.2.2 for a maximum travel distance of 200 feet from any point in a room to an exit. Due to the measured distance of 145 feet to an exit access door there is no exit within 55 feet of the exit access door for this room.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, because failure to construct and maintain fire resistive assemblies could allow fire and smoke to pass from one compartment into adjacent fire/smoke compartments.

Findings include:

A. Pipe or other penetrations through designated 2 hour fire/smoke separation walls was observed that is not capped against the passage of fire as required by 8.2.3.2.4.2. Locations observed include:

1. On the morning of 05/08/13, Building - 01, First Floor : Abandoned or discontinued pneumatic tube station located in the exit access corridor outside the Cancer Center penetrates the designated 2-hour fire/smoke separation wall was observed that is un-capped or not fire sealed.

2. On the morning of 05/08/13, Building - 01, First Floor - Family Health Center (FHC): The 4-hour "Chicago Vestibule" near the Welcoming Center/Registration Center was observed with a conduit penetration that is not fire sealed to comply with 8.2.3.2.4.2.

3. On the afternoon of 05/08/13, Building - 01, First Floor - Radiology Unit: Conduit penetrations located in the 4- hour Chicago Vestibule near the CT Scanner 2 Room were observed that are not fire sealed.

B. Doors in two hour fire barriers and designated 4 hour Chicago Vestibule are not constructed in accordance with 7.2.4. Locations include:

1. On the afternoon of 05/08/13, Building -01, First Floor - Designated two (2) hour fire separation wall was observed with a door that does not carry a 1 1/2 hour fire rating to comply with 8.2.3.2.3.1(1). This is the door to the Director's Office Room 1-338.

2. On the afternoon of 05/08/13, Building - 01, First Floor - Pair of doors to identified 4-hour Chicago Vestibule near the Family Health Center (FHC) west corridor were observed to be broken.

Based on random observation during the survey walk through while accompanied by the facility representative, light switches within the exit enclosure provided a manual means to discontinue illumination within a means of egress which does not comply with 7.8.1.2. This condition may prevent staff and visitors, within the exit stair, from a safe passage to an exit discharge

A. 05/7/13, at 1:50 pm and 05/8/13 at 10:45 am, Numerous exit stairs contain light switches at each floor landing. It could not be verified that the minimum continuous illumination level is being provided to comply with 7.8.1.3. The flipping of the switch turned off lights within the following example exit stairs:

1. Stair #3
2. Stair #4

11/01/13: The PoC for the above item does not include specific interim measures for the above items until the items are corrected.

Based on random observation during the survey walk-through while accompanied by engineering staff, not all egress paths are illuminated in such a manner that the failure of one fixture will not leave the area in darkness to comply with 39.2.9. 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.

The finding is::

A. 05/09/13 at 10:01 AM the 3rd floor battery powered emergency lighting did not comply with 39.2.9 and 7.9.2.1. due to the following:

1. Corrected 11/01/13

2. During an interview held in the office
of the building manager the battery
powered emergency lighting is not
tested at least 30 seconds every 30 days
to comply with 7.9.3.

11/01/13: The provider replaced some
devices completely and replaced the
batteries in other devices. The provide
lacks written documentation by device
and by location of each device, for each
month, from the date when the device
was repaired or replaced (previous three
to four months).

3. During an interview held in the office
of the building manager the battery
powered emergency lighting is not
tested at least 90 minutes every year to
comply with 7.9.3.

11/01/13: The provider replaced some
devices completely and replaced the
batteries in other devices. The provide
lacks written documentation by device
and by location of each device which
clearly indicates the date that the device
was replaced and tested and/or the date
where the battery was replaced and
tested.

Based on random observation during the survey walk-through while accompanied by engineering staff, battery powered emergency illumination is not provided in accordance with NFPA 101-2000, 19.2.9.1, 7.9 and NFPA 99-1999, 3-3.2.1.2. This deficiency could affect any patients, staff, or visitors on this floor level because the failure of the normal lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

A. 05/08/13 2:45 pm 3rd floor Delivery rooms (C-Section) were observed to not be provided with battery powered emergency lighting to comply with NFPA 99-1999, 3-3.2.1.2(a)5(e).

11/01/13: According to the provider's information there may be 14 locations with this same deficiency. A 6/15/2015 correction date is proposed. What specific interim life safety measures for location are proposed until correction?

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. and 7.10. 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.

Findings include:

A. Exit signs are not provided to identify the 2nd means of egress from corridors to comply with 19.2.5.9. Locations noted include the following:

1. It was observed at 2:30pm on 5/6/13 that the corridors north and south of the center meeting room at the Penthouse level lack exit signage on the corridor side of four doors to define the egress path to the other stair serving the floor level.

2. It was observed at 2:30pm on 5/7/13 that the 4th floor Paint Shop elevator lobby area lacked exit signage to define the available path of egress.

3. It was observed at 10:30am on 5/8/13 that the 4th floor corridors on each side of the smoke barrier doors near 411 lacked exit signage to identify the egress paths to a second exit.

4. It was observed at 10:45am on 5/8/13 that the 4th floor rooftop court utilized by patients is not provided with exit signage to identify the required egress paths.

5. It was observed at 10:45am on 5/8/13 that the 4th floor corridor outside the locked Behavioral Health unit lacks exit signage to identify access to two available exits. The doors at the secured unit are only operable by staff with a key in accordance with 19.2.2.2.4, Exception No. 1. However, occupants outside the locked unit who do not have keys are not capable of utilizing the doors. Exit signage is not provided to identify two available egress paths from the non-secured side of the Behavioral Health unit. The two sets of cross corridor doors at the corridors leading to the west are marked as egress paths only from the west side and are equipped with dead bolt locks operated with thumbturns from the west side and key from the east side. These doors can be locked to prevent egress from the east side. These doors swing against egress travel from the west side and are not identified as existing smoke barrier/horizontal exit doors as permitted by 7.2.1.4.2 Exception No. 1 or 2.

6. It was observed at 11:00am on 5/8/13 that the exit signage at the 2nd floor cafeteria cashier area is not directional to make clear the path to the Stairs and may inadvertently direct occupants into the serving line room.

7. It was observed at 1:30pm on 5/8/13 that the corridors north and south of the 1st floor Emergency Dept. lack exit signage to identify two compliant available paths of egress when cross corridor doors close.

8. It was observed at 1:35pm on 5/8/13 that the corridors outside the 1st floor G.I. Procedure room lack exit signage to identify two compliant available paths of egress when cross corridor doors close.

9. It was observed at 1:40pm on 5/8/13 that the corridor outside the Blood Bank on the 1st floor lacks exit signage to identify two compliant available paths of egress when cross corridor doors close.

10. It was observed at 2:00pm on 5/8/13 that the corridor west of the 1st floor Cashier suite lacks exit signage to identify two compliant available paths of egress when cross corridor doors close.

11. It was observed at 2:15pm on 5/8/13 that the Main Lobby lacks exit signage to identify a 2nd path of exit.

12. It was observed at 2:45pm on 5/8/13 that the corridor west of the Ear Nose & Throat Center lacks exit signage to identify two compliant available paths of egress when cross corridor doors close.

11/01/13: A 6/30/2015 correction date is proposed. What specfic interim life safety measures for location are proposed until correction?

B. Exit signs are inappropriately placed to define available exit paths. Locations observed include the following:

1. It was observed at 11:00am on 5/7/13 that the 8th floor Eye Clinic file room door to the workroom is provided with an exit sign but the door is equipped with locking hardware that prevents egress through the door the exit sign identifies. Surveyor notes that another marked exit door from the room is provided that does not prevent egress.

2. It was observed at 2:50pm on 5/8/13 that the Cath Lab 1 passage has exit signage which directs an exit path through a swinging door which is also equipped with a rolling shutter at the 4-hour barrier wall. The shutter did not close upon testing of the smoke detection provided at the opening to maintain the 4-hour barrier. The shutter is not a compliant means of egress component in accordance with 7.2.

3. It was observed at 10:15am on 5/9/13 that the Basement Mezzanine level (identified as an Exit Passageway) is provided with exit signage at the entrance to the Stair #5 exit stair. The door at this level swings against the direction of egress travel identified by the exit signage in noncompliance with 7.2.1.4.3. The 1st floor level of Stair #5 is marked within the stair with exit signage to identify the 1st floor as the level of exit discharge but the swing of the door at this level does not swing in the direction of egress travel to comply with 7.2.1.4.3. An interrupter gate is not provided at a discharge level to comply with 7.7.3 to prevent travel beyond the discharge level. The exit signage and the door swings did not match to determine which level was the intended discharge level.

4. It was observed at 10:30am on 5/9/13 that directional exit signage provided at the west end of the Basement Mezzanine level exit passageway directs the exit path to both Stair #7 and Stair #8. Stair #8 serves as an exit for the Basement level and discharges to the Basement Mezzanine level exit passageway which leads to Stair #7. Stair #8 is not an exit for the Basement Mezzanine level exit passageway.

5. It was observed at 11:30am on 5/9/13 that directional exit signage provided at the west end door of the Basement level material management storage area directs the exit path north and south prior to proceeding through the door which leads to the corridor leading to exit Stair #8. The directional exit sign at this location is not appropriate.

11/01/13: A 6/30/2015 correction date is proposed. What specfic interim life safety measures for location are proposed until correction?


16339

Based on random observation during the survey walk-through on 05/08/13, exit signs did not identify available paths of egress in all cases in accordance with 19.2.5.9, 19.2.10.1. and 7.10. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the smoke compartment or building.

Findings include:

C. On the afternoon of 05/08/13, Building - 01, 9th Floor - Med/Surg Unit: The exit access corridor by the Central Nurse Station lacks an exit signage to direct occupants to the nearest exit.

D. On the afternoon of 05/07/13, Building - 01, Fifth Floor-Rehabilitation Floor: The east exit access corridor near Room 512 was not provided with fully visible exit signage from all points in the corridor.

E. On the morning of 05/08/13, Building -01, Second Floor - Auditorium Building: One of the exit signs in the Auditorium was observed to not be continuously lit as required by 7.10.5.2.

11/01/13: A 6/30/2015 correction date is proposed. What specfic interim life safety measures for location are proposed until correction?

Based on document review, the facility's written plan for the protection of patients and visitors is not updated as required by 19.7.1.1. Failure to provide a specific information for exiting could result in a delayed response in a fire emergency.

Findings include:

A. Corrected 11/01/13

B. At 3:00pm on 5/8/13 it was observed that the Evacuation plan(s) posted in the Cath Lab area did not accurately depict the floor plan that existed. A review of the accuracy of the posted Evacuation plans throughout the building may be required due to renovation projects undertaken since the posting of the plans.

C. (New 11/01/13): At the time of this survey, the provider lacked the means to track and identify those items which have been confirmed by hospital personnel to be corrected.

Based on record review it was determined that the facility may not conduct fire drills at unexpected times under varying conditions, at least quarterly on each shift to familiarize facility personnel (nurses, interns, maintainance engineers, and adminsitrative staff) with the signals and emergency action as required.

Findings include:

A. Corrected 11/01/13

B. Corrected 11/01/13


20224


Based on document review and staff interview with facility engineering staff, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. These deficiencies could affect any patients, staff, or visitors in the facility because the staff may not be properly prepared to respond under emergency circumstances.

Findings include:

C. 05/08/13 at 9:10 am Based on document review, fire drills are not conducted at varying times to comply with 19.7.1.2. During the calendar year 2012, fire drills for the following quarters/shifts were conducted at the similar times and at the end of the month as listed:

1. First Shift:
a. 03/29/13 10:00am: .
b. 09/27/13 10:00am.
c. 12/21/12 10:00am

2. Second Shift:
a. 03/28/13 4:00pm.
b. 09/27/12 4:00pm

3. Third Shift
a. 9/28/12 5:30am
b. 12/21/12 5:30am

D. 11/01/13: The PoC has no correction date proposed and the provider did not institute immediate corrections.

1. Fire dill report forms are filled out for multiple locations where the observers are located during each fire drill; however, the specific location of each observer is not clearly identified at each individual form. The provider has multiple sheets for a 9-9-13 fire drill which all indicate the same thing without any deviation where the reports wee intended to document the response on different floors or in different zones.

2. The fire alarm system has been replaced and it has a new automatic voice annunciation system. The provider's fire drill report forms do not included whether personnel can hear the voice announcement in the area observed and does not include the voice announcement (location announced automatically) for each drill.

3. A fire drill for the 3rd shift was conducted on 09/09/13 at 5:00 AM. The provider was previously cited for not varying the times the fire drills are conducted. This has not been corrected to comply with 19.7.1.2. Only one floor was observed and documented for this drill.

4. A fire drill for the 2nd shift was conducted on 09/12/13 at 4:00 PM. The provider was previously cited for not varying the times the fire drills are conducted. This has not been corrected to comply with 19.7.1.2.

Based on random observation during the survey walk-through while accompanied by facility staff, patient sleeping rooms do not have visual access to the outside to comply with 19.3.8. These deficiencies could affect all patients within the area of the facility, as well as any staff and visitors present, by allowing those occupants to be trapped in a smokey fire incident.

The finding is:

A. 05/08/13 at 2:55 pm, 1st floor ICU patient rooms located along an interior wall of the building, on the South side of the suite do not have an outside window.

11/01/13: The 1st Floor ICU is cited for multiple deficiencies, not limited to K018, K029, K038 and K055. The PoC includes a 7/31/14 correction date but does not include a phasing schedule which identifies:

1. The submittal date for construction documents for a project or multiple projects to correct the above

2. Start date for construction project(s)

Based on observation during the survey walk-through, the facility failed to install and maintain automatic sprinkler protection in accordance with the requirements of NFPA 101-2000, 19.3.5, NFPA 13-1999, Chapter 5 and NFPA 25-1998, 2-2.1.1.

Findings include:

A. At 11:00am on 5/7/13 it was observed that the sprinkler protection provided at the 8th floor Mechanical room adjacent room 834-B was compromised by the lack of a ceiling and was open to the above ceiling space of adjacent areas. The room was not enclosed with 2-hour rated construction as indicated by the Life Safety Reference plans. The open ceiling can compromise the activation of the sprinkler protection provided for the room.

11/01/13: The PoC proposes a project submittal and a 2/28/15 correction date but does not identify any priorities and does not indcate why the above item should not be corrected immediately Specific interim life safety measures for teh above item are not identifeid until completion.

B. At 11:00am on 5/8/13 it was observed that the2nd floor Janitor closet adjacent Stair #4 230B contained an open ceiling access door which could not be secured in the closed position. The open ceiling can compromise the activation of the sprinkler protection provided for the room.

11/01/13: The PoC does not identify what temporary solutoins will be implemented and what Specific interim life safety measures for teh aboveneed to be implemented until completion.

C. On the afternoon of 5/8/13 it was observed that sprinkler head escutcheons were observed to be missing at the following locations:

1. At a head located in the Emergency Dept. Soiled Holding

2. At a head in the employee entrance vestibule south of the Emergency Dept.

3. At a head at the P.T. storage room 1-902B.

D. At 10:00am on 5/9/13 it was observed that the Basement level Soiled Laundry room sprinkler heads were covered with a heavy accumulation of lint and numerous ceiling access panels were left open. Both conditions can impair the activation of sprinkler protection.

11/01/13: The PoC proposes a project submittal and a 2/28/15 correction date but does not identify any priorities and does not indcate why the above item should not be corrected immediately. The above item should be corrected as part of teh annual testing and maintenance inspectoins of teh sprinkler system in accordance with NFPA 25.

E. At 10:20am on 5/9/13 it was observed that the Basement Mezzanine Ladies Washroom A-130 had a ceiling cutout which did not have an access door installed. The open ceiling can compromise the activation of the sprinkler protection provided for the room.

11/01/13: What temporary solutions are proposed?

F. At 10:30am on 5/9/13 it was observed that Electric room A-125 located at the Basement Mezzanine level was not sprinkler protected. The room was not maintained separated by 2-hour rated construction to comply with NFPA 13-1999, 5-13.11 Exception because the door was not self-closing to a latched condition.

G. At 10:45am on 5/9/13 it was observed that the Basement level OB/GYN training area was open to the above ceiling cavity at the old cobalt room sliding door head. The open head framing can compromise the activation of the sprinkler protection provided for the area.

H. At 11:00am on 5/9/13 it was observed that Electric room A-355 located at the Basement Mezzanine level near the Engineering offices was not sprinkler protected. The room was not maintained separated by 2-hour rated construction to comply with NFPA 13-1999, 5-13.11 Exception because the door assembly was not labeled as fire resistance rated.


14416

I. Based on direct observation, the facility failed to provide automatic sprinkler protection for the following areas.

1. Corrected 10/31/13
2. Electrical closet located within Room 1 109. This closet does not meet the exception of NFPA 13, 1999, 5-13.11 in that the enclosure appears to be of 2 hour rated construction however the door is not rated.
3. The electrical switchgear room B-302-B located in the basement does not meet the exception of NFPA 13, 1999, 5-13.11 in that the enclosure appears to be of 2 hour rated construction however the doors are held in the open position and do not close upon alarm activation
4. The emergency generators room is not provided with sprinkler protection. The exception of NFPA 13, 1999, 5-13.11 does not apply to this enclosure and the absence of sprinkler protection does not comply with NFPA 13, 1-6.1 & 5-1
5. The entry vestibule to the Day Surgery Department
6. The Outpatient entry vestibule
7. Electrical Closet 1-571
8. Corrected 11/01/13
J. Corrected 11/01/13


20224

Based on random observation during the survey walk, while accompanied by facility staff, failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors. The installation does not comply with NFPA 13 1999.

K. Corrected 11/01/13

L. The facility failed to provide fire suppression for the following area:

1. 05/07/13 at 1:30 pm, equipment alcove on the 11th floor (directly adjacent to Stair # 3) lacks sprinkler protection. The closest sprinkler head is located within the corridor and is more than 9 feet from the back wall of the alcove. This does not comply with NFPA 13, 5-5.5.1.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are inspected, tested and maintained in accordance with NFPA 25. This condition can lead to a poorly maintained system which can fail during a fire emergency affecting all patients, staff and visitors.

Findings include:

A. Sprinkler heads missing escutcheons to comply with NFPA 25 1998 2-2.1.1. Locations observed include:

1. Building - 01, Tenth Floor: Treatment Room 102A and the Janitor's Closet across Room 1015.

2. Building - 01, Fifth Floor: Room 517A Observation/ED. Case Management.

3. Building -01, First Floor: Pharmacy Office and Storage Room in the Pharmacy.

4. Building - 01, First Floor (Radiology Unit): Corridor near CT Scanner I.

5. Building - 01, First Floor (Radiology Unit): Room 1677.

6. Building - 01, First Floor IBCCP Room.

7. Building - 01, Basement - Engineering Office, Room B-117A.

8. Building - 01, First Floor - Designated 4-hour Chicago Vestibule near the CT Scanner 2.

B. Sprinkler head has been painted to not comply with NFPA 25 1998 2-4.1.8. Location observed include:

1. Building - 01, First Floor - Entrance to Family Health Center (FHC) Lobby.

C. Sprinkler heads were observed coated with dust to comply with NFPA 25 1998 2-2.1.1. Locations observed include:

1. Building - 01, First Floor - Flouroscopy Room near IR Holding.

Ventilation systems are not maintained in accordance with applicable standards.

Findings include:

A. At 3:00pm on 5/7/13 it was observed that the 4th floor patient's personal laundry facility, room 439, contained residential laundry equipment which vented the dryer exhausts to a duct and filter assembly which appeared to lack periodic cleaning and maintenance to comply with CFR 482.41(a). The lint filter assembly was full with lint to the point it was difficult to remove to check. The filter location on the floor behind the dryers was lint covered. It was not clear that the vent ductwork was functional or otherwise not severely restricted due to lint accumulation.

11/01/13: The surveyor observed that no corrective actions have been implemented and that the area behind the dryers was coated with lint. The surveyor further observed that only one of two dryer exhausts had an in-line lint trap behind the dryer and that that lint trap was clogged with lint build up. Based on these observations, the surveyor also expects to find the exhaust duct after the lint trap to be full of lint.

On 11/01/13, the surveyor required that the dryers be taken out of service until the above item has been corrected.


14416

B. Mechanical room #248: The surveyor did not find the installation of fire dampers for the duct penetration to the floor below or to the floor above from this second floor mechanical room. Through staff interview it was determined that fire dampers and protections are not provided for the duct penetrations of supply and return/exhaust ventilation systems originating in this second floor mechanical space. (NFPA 90A, 1999, 3-3.2)

C. On review of the fire and smoke damper inspection dated December 2008 there was no evidence to indicate deficiencies cited in that inspection have been corrected. The 4 year inspection has not been competed at this time. The facility indicated they would opt for the 6 year CMS Categorical Waiver for damper inspection and maintenance. However, correction of the 2008 deficiencies need to be completed.

11/01/13: The PoC does not indicate why any assessment is require from something which should have been completed in 2008. The PoC does not clearly indicate how a 2/28/2015 correction date of this item is necessary.

Based on observation during the survey walk-through, not all portions of the facilities commercial cooking equipment is installed and maintained in accordance with NFPA 96 1998.

Findings include:

A. Corrected 11/01/13


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B. By direct observation the surveyor finds the grease filter assemblies under the kitchen hoods to have gaps and spaces that allow grease laden vapor to bypass the filters.

11/01/13: The surveyor observed that the filters in the Kitchen hood had significant gaps between the filters and at the end of the filter racks at all of the Kitchen hoods in the kitchen. This condition allows grease to by-pass the filters and constitutes and fire hazard. The provider failed to correct this in accordance with the last submitted PoC and failed to implement adequate interim measures to insure that the deficiency is not repeated.

The above condition also applies to the grease filters in the hood above the cafeteria range where the filters are damaged and no longer grease tight.

Based on observation during the survey walk-through, not all portions of the building linen chute system are installed in accordance with NFPA 82-1999.

Findings include;

A. At 10:45am on 5/7/13 it was observed that the linen chute door on the 8th floor in room 805A was not positive latching to comply with 3-2.4.2.

11/01/13: The above chute door would not close to a latched position.

Based on observation during the survey walk-through and staff interview, not all portions of the building piped medical gas system are installed in accordance with NFPA 99-1999.

Findings include;

A. Medical gas piping zone valves were observed to lack labeling to adequately identify the locations served by the valves to comply with NFPA 99-1999, 4-3.1.2.14(b). Locations observed include:

1. Corrected 10/31/13

2. At 9:30am on 5/8/13 it was observed that the 4th floor medical gas valves near Soiled 432A and Janitor 415A were not labeled to identify the area(s) served. Surveyor notes that the Behavioral Health patient rooms do have medical gas outlets.

3. At 1:15pm on 5/8/13 it was observed that the 1st floor medical gas valves located within the Emergency Dept. may not be accurately labeled to identify all outlets served. Labeling indicated "Peds 1-7 Treatment 8-13", but treatment rooms 14-25 existed and a shut-off valve was not located.

4. At 2:00pm on 5/8/13 it was observed that a zone valve on the 1st floor near the service elevators was marked as serving "1-180 to 1-480" but the rooms could not be located.

5. At 11:00am on 5/9/13 it was observed that two oxygen zone valves located at the Basement level OB/GYN training area (old cobalt room) were labeled as serving "all rooms" rather than identifying the specific room(s) each valve served.


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B. Based on direct observation, the facility failed to provide separation of medical gas zone control valves from outlets and inlets they serve. The valves serving Cardiac Cath Prep/Recovery are located within the same room as the outlets and inlets they serve. NFPA 99, 1999, 4-3.1.2.3 (d).

11/01/13: The above item is also related to the K078 citation. Correction of both items may require 3rd party testing per NFPA 99. Revise the PoC as needed.


20224

Based on random observation during the survey walk-through while accompanied by engineering staff, not all piped-in medical gas systems are installed and maintained in accordance with NFPA 99.

Findings include:

C. 05/07/13 at 3:10 pm Manual medical gas shutoff (zone) valves were observed that are not labeled as to the station outlets they serve, this does not comply with NFPA 99 1999 Locations observed:

1. Third floor Delivery rooms.

2. Third floor LDR rooms

3. Third floor corridor leading to office adjacent to LDR #3.

Anesthetizing locations are not protected in accordance with NFPA 99-1999. This deficiency may result in discontinuation of medical gas services for patients outside the room of fire incident origin.

A. Based on direct observation, the facility failed to provide separate medical gas zone valves for Cath Lab #2. The same valves that serves the Cardiac Cath Prep/Recovery also serves Cath Lab 2 in non-compliance with NFPA 99, 1999, 4-3.1.2.3 (n).

Based on random observation during the survey walk-through while accompanied by a member of the engineering staff the surveyor found that the generator equipment does not meet all requirements of NFPA-110.

Findings include:

A. The five emergency generators did not have remote shut down switches to comply with NFPA-110, Section 3-5.5.6. This could affect emergency personnel in the event of a fire in the generator room.

11/01/13: A 9/30/14 correction date is proposed; what specific interim life safety measures will be implemented to mitigate this condition until it is corrected?

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.

11/01/13: Adequate interim life safety measures were not implemented. See each K-tag; a response is required where cited under each K-tag.

Based on random observation during the survey walk-through while accompanied by a member of the building engineering staff, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Findings include:

A. Some of the critical panels were serving items other than those allowed on the critical power system. Critical panels11CLB, 7CLA, 4CLB, 4CLC, and 3CLD had circuits feeding the fire alarm panels, med gas alarm panels, and elevator cab lighting (these items should be served from the life safety panel). This does not meet the requirements of NFPA-70, Section 517-32 and 33.

B. Critical panels PHCLA, PHCLB, BCLC (in loading dock area), and 2CLF are designated as critical panels, but they are serving mostly equipment and do not meet the requirements of NFPA-70, Section 517-33 and 517-34.

Based on observation during the survey walk-through, not all portions of the building electrical system is in accordance with NFPA 70-1999. Noncompliance can result in electrical shock hazard.

Findings include:

A. Corrected 11/01/13

B. At 1:40pm on 5/7/13 open junction boxes without covers were observed at the 6th floor Janitor closet 615A in noncompliance with NFPA 70-1999, 370-25.

11/01/13: The proposed correction date for teh above item is not reasonable; it can be corrected in ten to twenty minutes.

C. Corrected 11/01/13

D. Corrected 11/01/13

E. At 10:45am on 5/8/13 open junction boxes without covers were observed at the 2nd floor Kitchen at the west end of the large hood pedestal wall in noncompliance with NFPA 70-1999, 370-25.

11/01/13: The proposed correction date for teh above item is not reasonable; it can be corrected in ten to twenty minutes.

F. At 10:00am on 5/9/13 an open junction box without cover was observed above the ceiling at the 1st floor near the discharge of Stair #4.

11/01/13: The proposed correction date for teh above item is not reasonable; it can be corrected in ten to twenty minutes.


17659


Based on random observation during the survey walk-through while accompanied by a member of the building engineering staff, the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

G. Normal power receptacles were not provided in the first floor endoscopy room, cystoscopy room, and in pediatrics rooms 629 and 630, treatment rooms in same day surgery as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

H. Bonding of the piping for the medical gas system could not be located by staff as required by NFPA-70, Section 250-104(c). This could cause a potential difference between med gas piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

I. The operating rooms, and procedure rooms in same day surgery were not equipped with battery lights to comply with NFPA-99, Section 3-3.2.1.2(a)5e. During surgery battery lights provide lighting upon loss of power during the transition from normal to emergency power.

11/01/13: What specific interim life safety measures will be implemented to mitigate this condition until it is corrected?


J. The water service was not grounded at the main water service entrance in accordance with NFPA-70, Section 250-50. This could create a shock hazard for all building occupants.

K. Electrical panels 1LP-L01 in the ENT center, panel 2EM-3, and kitchen panel PK5 need blanks over empty circuit breaker spaces to comply with NFPA-70, Section 110-12(a).

11/01/13: The proposed correction date for teh above item is not reasonable; it can be corrected in ten to twenty minutes.



20224


Based on random observation during the survey walk-through, while accompanied by engineering staff, electrical wiring and equipment was not installed and maintained in accordance with NFPA 70 National Electric Code and NFPA 101, 9.1.2. This deficiency could result in exposure of occupants to electrical shock.

Finding is:

L. 05/06/13, 2:00 pm, 12th floor Electrical panel located in Communication closet 1219 A was observed with an open breaker space missing complete enclosure to comply with NFPA 70-1999, 384-18.

11/01/13: The proposed correction date for the above item is not reasonable; it can be corrected in ten to twenty minutes.

M. 05/07/13 at 2:00 pm Through direct observation Normal power receptacles were not provided in the following locations to comply with NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1:

1. 1st floor Operating rooms
2. 1st floor Stage I Recovery room
3. 3 rd floor Delivery rooms
4. 3 rd floor LDR rooms

N. 05/07/13 at 2:00 pm Emergency power electrical receptacles are not labeled to identify the circuit and panel from which they are fed to comply with NFPA 70-1999, 517-19 a. This condition was observed throughout critical care areas of the facility. Example locations include:

1. 1st floor Operating rooms
2. 1st floor Stage I Recovery
3. 3rd floor Delivery rooms (C-Section)
4. 3rd floor LDR rooms

17659


11/01/13 - moved from K161

Based on random observation during the survey walk-through while accompanied by a member of the building engineering staff, the surveyor found that portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

A. The surveyor did not find a single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation of each elevator as required by NFPA-70, Section 620-53.

B. The surveyor did not find that the disconnect for the emergency lighting and controls for each elevator was fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

C. The surveyor observed that the hydraulic elevator machine rooms were equipped with sprinklers, but there was not a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.


A) Based on personnel interview, including the CEO and the Director of Engineering, on 11/01/13, the provider indicates that eleven of eleven traction elevators in their facility do not comply with the automatic recall requirements to a primary floor and to an alternate floor in accordance with the requirements of ASME A17.1.

The extent of this condition was not determine by the surveyor. The surveyor also did not attempt to determine whether this condition applies to multiple hydraulic elevators.

A phasing schedule for the correction of each deficient elevator was not available.

17659


11/01/13 - moved from K161

Based on random observation during the survey walk-through while accompanied by a member of the building engineering staff, the surveyor found that portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

A. The surveyor did not find a single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation of each elevator as required by NFPA-70, Section 620-53.

B. The surveyor did not find that the disconnect for the emergency lighting and controls for each elevator was fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

C. The surveyor observed that the hydraulic elevator machine rooms were equipped with sprinklers, but there was not a heat detector within 2' of each sprinkler head to initiate a shunt trip device to automatically disconnect the main power supply prior to the application of water in the machine room or shaft as required by ASME A17.1-102.2.c.3.


A) Based on personnel interview, including the CEO and the Director of Engineering, on 11/01/13, the provider indicates that eleven of eleven traction elevators in their facility do not comply with the automatic recall requirements to a primary floor and to an alternate floor in accordance with the requirements of ASME A17.1.

The extent of this condition was not determine by the surveyor. The surveyor also did not attempt to determine whether this condition applies to multiple hydraulic elevators.

A phasing schedule for the correction of each deficient elevator was not available.