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

Findings include:

On 08/11/2021 at 11:00am while in the company of the BE it was observed that Delayed Egress locks are installed which lack the required signage indicating a 15 second delay for release of the lock. This condition does not comply with 7.2.1.6.1.1.(4). Example locations include:

1. Fifth floor Labor and Delivery Department.
2. Third floor Pediatrics

Based upon observation, Stairways are not maintained in accordance with Code requirements. Failure to maintain Code compliant stairways can impair building occupants' use of the stair for egress from the building during a fire/smoke event.

The finding is:

On 08/11/2021 at 11:45am while in the company of the BE it was observed that the North stair within the Annex building serving 4 stories and the roof lacks guard rails at landings to comply with 7.2.2.4.4.3 for a height no less than 38" and no more than 42 inches. The stair runs are approximately 66" apart which is greater than the 12" permitted by CMS for approved existing stairs.

Sleeping suites are larger than permitted. Failure to limit the size of sleeping suites can compromise the safety of patients and staff with regard to exit access travel distances and compartmentalization in the event of a fire/smoke event.

The finding is:

On 08/10/2021 at 10:20am while in the company of the BE during review of the facility Life Safety Plans the surveyor observed that sprinklered sleeping suites are noted to be larger than the permitted 7500 sf when not provided with total coverage of a smoke detection system to comply with 19.2.5.7.2.3(C). During discussion of the suite size the facility representative did not know the reason as to why the Med-Surg area is a suite.
Location observed The 10,365 sf 3rd floor medsurg suite

Based on observation, 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:

On 08/10/2021at 1:05pm while accompanied by the BE, means of egress areas through out the building lack exit signage to comply with 7.8.1.2 and 19.2.8.
Example location observed: Fourth floor Psychiatric Care Unit lacks exit signage at both north end doors leading to Corridor C402 (on the life safety floor plan).

Based upon observation, vertical openings are not protected to maintain separation of floor levels. Failure to maintain separation of floor levels can result in the spread of fire/smoke conditions from one floor to another.

Findings include:

A. On 08/10/2021at 11:30am while in the company of the BE it was observed that holes are present in the 2 hour fire rated shaft wall of the elevator. Location observed the 5th floor nurse station in the Med\Surg wing. This does not comply with 19.3.1.1 and 8.2.5.4

B. On 08/10/2021at 11:30am while in the company of the BE it was observed that holes are present in the 2 hour fire rated floor which contain wood block patches. Location observed the 5th floor nurse station Med\Surg wing. This does not comply with 19.3.1.1 and 8.2.5.4

C. On 08\10\2021 at 11:45am while in the company of the BE duct work penetrating the Psychiatric Wing 7th floor "split level" mechanical room located adjacent to the elevator lacks an access panel for damper inspection. Therefore it is unknown if a through floor damper is present. This condition does not comply with NFPA 80 2010 19.2.3.2 and 6.3.2.2 for the presence of an access panel and the presence of a fire damper. .

D. On 08/11/2021 at 1:50pm while accompanied by the BE a hole in the 2-hour fire rated wall of an exit stair was observed. Location observed: North West Stair fifth floor east wall near the floor of the landing.

Based on observation the facility failed to install a compliant Category 1 Medical Gas System. This deficient practice could result in the failure / response which may affect patients, staff and visitors during a fire event.

The finding is:

On 08\10\2021 at 2:50pm in the company of the BE a zone valve was observed installed within the same space for the outlets/inlets it controls and not placed on an intervening wall. This condition does not comply with NFPA 99, 2012, 5.1.4.8 Location observed: Fifth floor C-Section room.

Based on observation the facility failed to document inspection of the kitchen / cafeteria hood fire suppression system. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 08/11/2021 at 11:25 am in the company of the FM observation of the inspection tag for the grease hood fire protection system, it was observed the record of the date and initials of the person completing the monthly inspection is not provide on the tag. NFPA, 17, 2009, 11.2.4 / NFPA 17A, 2009, 7.2.5.

Based on observation that not all portions of the building fire alarm system are installed in order to provide for prompt evacuation of an area or room. This condition may prevent emergency egress from the location of fire origin to an adjacent compartment. This condition may affect patients, staff and visitors throughout the facility.

Findings include:

A. On 08/10/2021 at 2:15pm, while in the company of the BE, a fire alarm manual pull station was observed that is not installed within 5' of the exit stair entry door in order to comply with NFPA 72, 2010, 17.14.6. Location observed: Sixth floor East Stair.

B. On 08/11/2021 while accompanied by the BE Staff sleep rooms (on-call) lack an approved single station smoke alarm notification device to comply with 18.5.4.6 of NFPA 72, 2010 and 29.5.1.1(1) of NFPA 72, 2010. Example locations include fifth floor on call rooms adjacent to Labor and Delivery.

C. On 08/11/2021 while accompanied by the BE Staff sleep rooms (on-call) lack an approved visual notification device to comply with 18.5.4.6 of NFPA 72, 2010 and 29.5.1.1(1) of NFPA 72, 2010. Example locations include fifth floor on call rooms adjacent to Labor and Delivery

Based on observation that not all portions of the building fire alarm system are installed in order to provide for prompt evacuation of an area or room. This condition may prevent emergency egress from the location of fire origin to an adjacent compartment. This condition may affect patients, staff and visitors throughout the facility.

Findings include:

B. On 08/10/2021 at 1:30pm while accompanied by the BE Staff sleep rooms (on-call) lack an approved single station smoke alarm notification device to comply with 18.5.4.6 of NFPA 72, 2010 and 29.5.1.1(1) of NFPA 72, 2010. Example locations include fourth floor on call rooms.

C. On 08/10/2021 at 1:35pm while accompanied by the BE Staff sleep rooms (on-call) lack an approved visual notification device to comply with 18.5.4.6 of NFPA 72, 2010 and 29.5.1.1(1) of NFPA 72, 2010. Example locations include fourth floor on call rooms.

Based on observation the facility failed to install a complete building wet pipe fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

Findings include:

A. On 08/10/21 at 1:10 pm accompanied by the BE, it was observed that fire sprinkler protection for the all facilities traction elevator machine rooms is not provided. NFPA 13, 2010, 8.1.1
Note: There appears to be chemical fire suppression devices installed, however the facility could not provide information as to the type of system installed nor documentation of inspection and testing of these systems.


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B. On 08/10/2021 at 1:50pm while accompanied by the BE a shelf deeper than 12 inches was observed located below a sprinkler head. The shelf forms an obstruction to adequate sprinkler protection for this room. This condition does not comply with NFPA 13 2010 8.1. Location observed: Sixth floor Linen room located in the ICU.

C. On 08/10/2021 at 1:45pm while accompanied by the BE a sprinkler head was observed the construction lock remaining (orange colored). This lock prevents sprinkler operation. This condition does not comply with NFPA 13 2010. Location observed: Sixth floor closet near the Stress Lab.

Based on document review and staff interview the facility failed to record required electrical measurements and testing for annual fire pump testing as required by NFPA. Failure of the fire pump during a fire event risk safety of patients, staff and visitors.

The findings is:

On 08/11/2021 at 10:00 am in the company of the DPOM review of the annual fire pump test finds that a record of the fire pump being tested under emergency power could not be provided. NFPA 25, 2011, 8.3.3.4

Based on observation the facility failed to document inspection of all facility portable fire extinguishers. This deficient practice could affect patients, staff and visitors during a fire event.

Accompanied by the BE observation of the inspection tags recording the date and initials of the person completing the monthly inspection is not provided on the tag at the following date/times and locations: (NFPA 10, 2010, 7.2.1.2)

1. 08/10/2021 at 1:45 pm Elevator Machine Room 6
2. 08/10/2021 at 1:55 pm Elevator Machine Room 7
3. 08/11/2021 at 11:00 am 1st Floor Phycisians Center Mechanical Room

Based upon observation, corridor doors are not positive latching. Failure to provide positive latching corridor doors can compromise the effectiveness of the door to remain closed to prevent the passage of smoke from one side of the corridor wall to the other.

Findings include:

A. On 08/10/2021 at 1:30pm while in the company of the BE, it was observed that corridor doors were equipped with a thumb turn lockset on the egress side with no latching hardware to allow the door to close to a latched condition. This does not comply with 19.3.6.3.5 for a corridor door which is required to have a means for keeping the door in the closed position (latched not locked). Closing and latching the door requires several operations rather than one motion which does not comply with 7.2.1.4.1 (4) (c), 7.2.1.5.10.2. Location observed: Sixth floor Diagnostic Center multiple sliding doors.

B. On 08/10/2021 at 1:40pm while in the company of the BE, it was observed that corridor doors were equipped with multiple locking devices. This does not comply with 7.2.1.5.10.2 for requiring the door be opened wth no more than one releasing operation. Location observed: Sixth floor Diagnostic Center Room #606.

Based on observation and document review inspection reports do not provide the required information per the current codes and standards. This deficient practice may affect all patients, staff and visitors within the building should a component of an essential system fail during a fire event.

The finding is:

On 08\11\2021 at 9:25am while accompanied by the PDOM review of documents for fire and smoke damper maintenance and inspections are not complete to comply with NFPA 80 2010, 19.4.9 and NFPA 105 2010 6.6.3. The finding is that the latest test report dated January of 2019 does not include floors 5, 6 and 8 within the 6 year inventory and testing. Surveyors observed dampers in the "attic space" within the top of the building gable at and above the 8th floor which are not accounted for in the document.

Based upon review of record documentation of door inspections, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. Failure to maintain doors can compromise adjacent spaces during a fire condition.

The finding is:

On 08\11\2021 at 10:00am while in the company of the DPOM, documentation for fire rated doors was reviewed.
There is no indication a complete fire door inspection was conducted for 2021 to comply with the requirement of 7.2.1.15.
There are corrective measures which do not match the deficiency cited for a particular door. For example - Door #084517 reads that it is damaged and lacks a smoke seal. The corrective action refers to shimming the bottom bolt hinge, without any reference to a smoke seal replacement.
Another example - Door # 0001 Stairwell door lacks an indicated fire rating, the correction reads that a penetration was sealed which does not relate to the lack of an indicated fire rating. The corrective actions/modification recieved are not indicated to comply with NFPA 80 2010, 5.1.5.1 for an immediate resolution.

Based on observation the facility failed to identify components of the Category 1 medical gas systems. This deficient practice could affect patients during treatment while using these systems.
The finding is:

A. On 08/10/2021 at 1:15 pm accompanied by the BE, it was observed that the source valves for the piped medical vacuum systems are not labeled or identified as to their function as require by NFPA 101, 2012, 19.3.2.4 / NFPA 99 2012, 5.1.11.

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

B. On 08/10/2021 at 2:00 pm accompanied by the BE, it could not be confirmed through observation and staff interview that bonding of the facility's medical gas piping system has been completed. This is not in compliance with NFPA 70, 2011, 250.104 (B)