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Based an observations, not all exit doors required to be self closing are installed or maintained to permit egress and provide protection of the exit enclosure. This deficiency could affect patients, staff and visitors if the exit access door did not provide the proper protection during a fire emergency.

The finding is:

On 03/10/25 at 10:10 am while accompanied by the FS it was determined that not all exit components are provided with elements that maintain the fire resistant rating of the enclosure. Exit stair door hardware components did not provide a self closing assembly. This does not comply with the requirements of 19.3.1. 19.3.6.3.11

Location obsetved:
Exit door at the top of Stair #1 (used as an exit from the Penthouse).

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

The finding is:

At 11:20 am while in the company of the FS it was observed that the exit stair #S2203 also known as stair #3 lacked guards to prevent a 4" sphere from passing through the guard rail (or 6" sphere at the riser/tread triangle) to comply with 19.2.2.3, 7.1.8, 7.2.2.4 and 7.2.2.4.5.3. The exit stair is considered a means of egress for Second through Ground levels.

Based on observation, battery powered emergency lighting system is not maintained in accordance with Code requirements. Failure to properly perform maintenance activities can result in failure of the lighting system affecting patients, staff, and visitors.

Findings include:

A. On 3/10/2025 at 9:50 a.m. while in the company of the FS. it was observed that a battery powered emergency luminaire was not operational. The units battery appeared to not be charged. There is a switch installed on the unit which was in the off position, this appeared to prohibit the proper functioning of the units battery which is not in compliance with NFPA 70, 2011, 700.20.
Location observed: Fourth floor Mechanical room 4002


Based on observation, not all portions of the electrical system are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the emergency lighting could fail to operate properly when needed if they are not properly installed.

Findings include:

B. On 3/10/25 at 11:15 a.m. while in the company of the F.S. it was observed that a battery powered emergency luminaire was supplied from a receptacle not determined to be on a lighting circuit to comply with NFPA 70 2011 700.12(F).
Location observed: First floor corridor C1104, across from Operating Room 1105

C. On 3/10/25 at 11:30 a.m. while in the company of the F.S. it was observed that a battery powered emergency luminaire was supplied from a receptacle not determined to be on a lighting circuit to comply with NFPA 99 2012, 6.3.2.2.11.3.
Location observed: Operating Room 1105

Based upon observation, exit signs are not provided to identify access to two remote exits from the building. Failure to provide exit signs to correctly identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition.

The finding is:

On 03/10/25 at 10:35 am while accompanied by the FS it was observed that corridors lacked proper exit signs to clearly identify access to at least two remote means of egress from the building to comply with 19.2.4.3, 19.2.10 and 7.10.
Location observed: Second floor corridor (containing Wound Care Clinic) leading to Stair S3304.

Based on observation, not all vertical openings in the building are protected as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass between building stories if vertical openings are not protected.

Findings include:

On 03/10/25, while accompanied by the FS, observation determined that a water pipe had been installed through the 2 hour fire rated enclosure walls and into the exit stair enclosure, this pipe installation goes through the stair and does not serve the stair which does not comply with 7.1.3.2.1(10). .
Locations observed: Lower Level Exit Stair #3 shared wall with Mechanical room

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting.

The findings are:

A. On 03/10/25 at 10:10 am while in the company of the FS it was observed that a door to storage room contains a closer with a hold open therefore the door is not self closing to comply with 19.3.2.1.3. Location observed : third floor room #342.

B. On 03/10/25 at 10:50am while in the company of the FS it was observed that a door to a sprinklered soiled utility room lacks the requirements to maintain a smoke tight installation to comply with 19.3.2.1.2, 8.4 due to containing a 1 inch by 2 inch hole filled with wood putty of unknown materials. Location observed Second floor soiled utility room #2003 near Pharmacy.

C. On 03/10/25 at 10:55am while in the company of the FS it was observed that the ceiling within a sprinklered soiled utility room lacks the requirements to maintain a smoke tight installation to comply with 19.3.2.1.2 due to unprotected conduit penetrations and holes within the ceiling tiles. Location observed Second floor soiled utility room #2003 near Pharmacy.

Based on observation, the facility failed to install and maintain its piped medical gas system as required. This deficient practice could affect patients, staff, and visitors in the building because the piped medical gas system could fail to operate when needed if not properly installed and maintained.

The finding is:

On 03/10/25while in the company of the FS it was observed that medical gas shut off valves for any critical care, life support and anesthetizing location also served other locations. This is not in accordance with NFPA 99-2012, 5.3.6.19.3
Locations observed:

1. At 11:46am third floor med/surg patient rooms medgas outlets and the medgas outlets in the Special Procedure rooms (which was a remodeled area not part of original building) share the same shutoff valves.

2. At 11:16am second floor med/surg patient rooms #201-#214 medgas outlets and the medgas outlets in the Intensive Care rooms #259, #267 and #268 share the same shutoff valves.

Based on observation, not all spaces open to exit access corridors are protected in accordance with Code requirements. Failure to provide protective features can compromise the use of corridors during a fire condition.

Findings include:

On 03/10/25 at 10:50 am while in the company of the FS areas open to the corridor were observed, that lacked smoke detection or continuous supervision to comply with 19.3.6.1. Through staff interview it was determined that the door to this room remains in the open position at all times.
Location observed: ICU Waiting room

Based on observation, the facility failed to install and maintain its piped medical gas system as required. This deficient practice could affect patients, staff, and visitors in the building because the piped medical gas system could fail to operate when needed if not properly installed and maintained.

The finding is:

On 03/10/25 At 11:20am while in the company of the FS it was observed that medical gas outlets for vacuum are present within the ICU however gas zone valves serving these outlets could not be located. This is not in accordance with NFPA 99-2012, 5.1.4.8.4 Location observed Second floor

Based on observation during survey walk through, egress from the working space around electrical equipment is not maintained in accordance with Code requirements. This deficiency could affect staff and visitors in the event of an electrical equipment failure.

Findings include:

A. On 3/10/25 at 1:00 p.m. while in the company of the FS. it was observed that doors intended for entrance to and egress from electric rooms G210A and G210B were not equipped with hardware that releases with simple pressure, therefore not in compliance with NFPA 70 2011, 110.26(C)(3).


Based on direct observation during survey walk through, not all portions of the electrical system are constructed in accordance with Code requirements. This deficiency could affect patients and staff in the event of electrical equipment failure during a procedure.

Findings include:

B. On 3/10/25 at 11:45 a.m. while in the company of the F.S. it was observed that the isolated power systems serving rooms did not include a line isolation monitor visible within the room. This condition does not comply with NFPA 99 2012, 6.3.2.6.3.4.
Example locations Operating rooms 1107 and 1109

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

Findings include:

A. On 03/10/2025 at 9:45 a.m. while in the company of the F.S. it was observed that receptacles installed in the fourth floor elevator machine room were not equipped with G.F.C.I. protection for personnel. This condition does not comply with NFPA 70, 2011, 620.55.


B. On 3/10/2025 at 10:55 a.m. while in the company of the F.M. it was observed that receptacles located in the second floor Pharmacy room 2006 were labeled as being supplied from the equipment branch of the essential electrical system which does not comply with NFPA 99 2012, 6.4.2.2.5

Based on observation, not all portions of the essential electrical system are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical systems could fail to operate properly when needed if they are not properly installed.

Findings include:

A. On 03/10/25 while in the company of the FS the surveyor observed branch circuit panels installed not marked to identify the device or equipment where the power supply originates. The labeling convention could not be determined to identify and locate the panel and circuit from which the receptacle was fed. therefore this does not comply with NFPA 70 2011, 408.4(B) 517.30 (C).
Example locations:

1. At 10:25 am Third floor Endo Procedure rooms, Recovery rooms
2. At 11:20 am Second floor ICU
3. At 11:36 am Second floor Surgery area


B. On 3/10/25 at 9:42 while in the company of the F.S., inside the fourth floor elevator machine room it was observed that lighting for the elevator cars is not supplied by the Life Safety branch of the Essential Electrical System, therefore not in compliance with NFPA 99 2012, 6.4.2.2.3.

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

Findings include:

On 3/10/25 at 9:40 a.m. while in the company of the FS. it was observed that an externally operable disconnecting means for elevator car lighting has not been provided in the fourth floor elevator machine room, therefore not in compliance with NFPA 70 2011, 620.53.