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Based on observations the facility failed to provide a building with an acceptable construction type. This deficient practice could affect patients, staff and visitors if a fire in the deficient area were to compromise the buildings structural integrity during a fire emergency.

Findings include:

On 10/25/2022 at 10:05 am while accompanied by the CM, it was observed a steel beam which lacks fire proofing. The beam is located in the Mechanical Penthouse of the Classic building. This does not comply with Table 19.1.6.1 and NFPA 220 2012 Ed. Table 4.1.1.

Based on observation, not all egress paths are maintained in accordance with Code requirements. This deficient practice could affect patients, staff and visitors if failure to maintain required means of egress can impede the use of the means of egress by building occupants during emergency conditions.

Findings include:

A. On 10/24/22 at 2:40 PM while in the company of the FOM it was observed that 1st floor Corridor T1125 was identified with exit signage directing exiting into/thru the SE corner of the ICU suite in non-compliance with 7.5.1.2 and 19.2.5.4..

Based on observation, means of egress doors are locked using noncompliant methods. Failure to install locking devices for means of egress doors in full compliance with all requirements can result in building occupants not being able to reach an area of safety or an exit during a fire/smoke event.

The findings are:

A. On 10/26/2022 at 9:35 am, while accompanied by the CM, the designated exit sliding doors (2 sets) from the ER to the exterior are locked against egress at all times. The means of egress from the ED is not available unless a nursing staff allows exiting, not all facility staff contain the means to unlock the doors. This condition does not comply with all of the requirments of 19.2.2.2.5.2. (1)-(5).
Location 2 pairs of sliding doors from the ED to the exterior.


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B. On October 24, 2022, at 2:30pm while in the company of the FMBG and FSM, it was observed on the 3rd floor of the Classic Building that Exit Stair #9 is provided with a compliant delayed egress lock. The door, however, is also installed with keyed cylinders on both sides of the passage set door hardware. Therefore, this installation is not in compliance with 19.2.2.2.4.

C. On October 24, 2022, at 2:50pm while in the company of the FMBG and FSM, it was observed on the 4th floor of the Classic Building that pad locks with hasps are installed on rooms located off Corridor 4056. Therefore, these installations are not in compliance with 19.2.2.2.4.

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 10/26/2022 at 9:05am while accompanied by the CM exit signage is obstructed from view and does not comply with 7.10.1.8. Location observed, Second floor "Classic building" corridor leading to CICU from Stair #1 at pair of cross corridor doors.

Based upon observation, vertical openings are not constructed and maintained to provide separation and continuous fire resistant construction in accordance with requirements. This deficient practice could affect patients, staff and visitors if a failure to protect vertical openings would permit the effects of a fire/smoke to expose and compromise the safety of occupants utilizing an exit stair.

The finding is:

On 10/24/2022 at 2:25pm while accompanied by the CM an hvac shaft was observed to not be completely enclosed with a minimum 2-hour fire rated construction due to a 74"x44" sheet meal cover in the East wall of the shaft. This condition does not comply with 8.3.5.1, 8.3.5.7, and 9.2.1. Location observed: 2nd floor mechanical room #2026 large vertical shaft.

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

Findings include:

A. On 10/24/ 2022 while in the company of the CM areas were observed being used for the storage of equipment, cardboard boxes for Labor and Delivery greater than that for the normal area's function. Example locations:

1. At 2:25pm 4th Floor Elevator #9 Lobby area is being used as storage. Approximately 6 pallats with cardboard boxes stacked 4 to 5 boxes high on each pallat are being stored within the Lobby and more are being stored in the adjacent means of egress corridors. This condition does not comply with 19.3.2.1, 8.7.1 & 8.4.

2. At 2:56 pm 2nd floor Exhaust Fan/Mechanical room #2004/#2003 is a mechanical room that is open to a shaft above. This mechanical room is therefore the bottom part of a shaft. This mechanical room does not comply with 19.3.1, 8.6.4.2 for having a use related to the purpose of the shaft due to being used for storage by containing over 20 cardboard boxes, shelving with diffusers, parts of duct work etc.


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B. On 10/25/2022, at 10:05am while in the company of the FSM, it was observed on the ground floor that the northern most double doors serving Environmental Serv. Stor. Neg002, a room designated as hazardous on the Life Safety plans, did not self-close when tested. The inactive leaf with astragal did not close first because the door coordinator did not function properly. This does not comply with 19.3.2.1.3.

Based on observation during the survey walk through the facility failed to provide protection and identification for the fire extinguishing components. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 10/25/22 at 9:50 AM in the company of the FOM, the facility failed to provide the required K Fire Extinguisher in a convenient and accessible location in the path of exit egress away from a fire for the cafeteria. This condition does not comply with NFPA 96, 2011, 10.10

Based on observation fire alarm system components are not installed and maintained in accordance with Code requirements. Failure to install components in accordance with requirements can result in failure of the system to operate as intended and delay proper repairs when necessary.

Findings include:

A. On 10/25/2022, at 9:45am while in the company of the FSM, it was observed on the ground floor in Vest TGR067 that the fire alarm panels are not labeled to identify the panel and circuit from which they are fed to comply with NFPA 72-2010, Section 10.5.5.2.1.

B. On 10/25/2022, at 10:30am while in the company of the FSM, it was observed on the ground floor in Info Systems/Clinical Informatics G073A, as shown on the Life Safety Plans, that substantial gaps exist between the ceiling membrane and various electrical penetrations. The missing ceiling material would allow heat and products of combustion to bypass the installed smoke detector. Therefore, the installation does not comply with NFPA 72-2010, 17.7.3.2.4.2.

Based upon documentation, fire alarm system components are not installed and maintained in accordance with Code requirements. Failure to install components in accordance with requirements can result in failure of the system to operate as intended and delay proper repairs when necessary.

Findings include:

On 10/25/2022, at 11:00am while in the company of the MLF the Fire Alarm inspection documentation indicated that the NAC panel batteries in the sprinkler room and the second-floor electrical room failed the load test. No documentation was provided to indicate that the batteries had been replaced. This is not in compliance with NFPA 72-2010, 14.2.1.2.2.

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. On 10/26/2022 at 10:50am while accompanied by the CM within Maintanence #215 located on the second floor of the "classic building" sprinkler protection is lacking for the area above the suspended acoustical tile ceiling of the "Key Room" to comply with NFPA 13 2010 8.1.1 (3), 8.5.3.2.1 distance from sprinklers to walls.

B. On 10/26/2022 at 1:50pm while accompanied by the CM within the Surgery Sterile Core sliding tracked storage system was observed with plexiglass sheeting attached to the top of each unit. This condition does not comply with NFPA 13 2010 8.8.5.2 for obstructions to sprinkler discharge pattern.

C. On 10/25/2022 at 11:12am while accompanied by the CM the second floor level of Stair #4 at the top of the ladder sprinkler protection is lacking in the ceiling pocket. This condition does not comply with NFPA 13 2010, 8.6.7


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D. On 10/25/2022 at 9:55 AM while accompanied by the FOM, a roughly 2-3 inch opening around a sprinkler head was observed in the kitchen on the Ground Floor. This condition can delay activation of a sprinkler head by allowing heat and combustive materials to by pass the sprinkler. This condition does not comply with NFPA 13-2010, 6.2.7 as part of a listed sprinkler assembly and 8.1.1.(3) for activation time.

Based on observation, not all corridor doors are installed and maintained to remain in the closed position. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass into corridors if the corridor doors are not installed in a compliant manner.

The finding is:

On 10/25/2022 while accompanied by the CM corridor doors do not positively latch to a closed position which does not comply with 19.3.6.3, 7.2.1.4.5.1 (door leaf operating force to release a latch). These corridor doors were considered new as constructed under NFPA 101 2000 ed to comply with 18.3.6.3.2 (no exceptions). Considered as existing now shall not further diminish the previous requirments for new construction.
Example locations observed:

1. At 1:38pm pair of corridor doors from ED suite to Corridor #1799EB (part of waiting area).
2. At 1:42pm pair of corridor doors from ED suite to Corridor #1799EP (adjacent to EVS/sprinkler rm)
3. At 1:45pm pair of corridor doors from ED suite (corr #1799EX) to Corridor #1799EN (adjacent to Triage A)
4. At 1:24pm pair of door to Storage 1311P from Corridor #1399PC are slow auto closing that do not latch.
5. At 2:20pm door from Sub Sterile adjacent to OR #11 does not latch.

Based on observation the facility failed to separate environmental ventilation ducts from kitchen grease and laboratory hood exhaust ducts within the fire rated enclosing shaft. This deficient practice could result in the uncontrolled spread of fire and products of combustion during a kitchen hood/duct fire event, which may affect patients, staff and visitors.

Findings include:

A. On 10/25/2022 at 12:00 PM while accompanied by the FOM, through observation and staff interview the kitchen grease hood exhaust duct appears to be within the same enclosure as supply/return ducts serving other areas of the facility. This condition does not comply NFPA 96. 2008 7.1.3.1 and 7.7.2.1.2 for a minimum 2-hour fire rated enclosure of the grease duct itself.

Locations observed: Roof of classic building above shaft, second floor mechanical room #2026 suspect shaft T2016 and plan documents.

B. On 10/25/2022 at 12:00 PM while accompanied by the FOM, through observation and staff interivew a laboratory hood exhaust duct appeared to be within the same enclosure as supply/return ducts serving other areas of the facility. This condition does not comply NFPA 96. 2008 7.1.3.1 and 7.7.2.1.2 for a minimum 2-hour fire rated enclosure of the laboratory hood duct itself.

Location observed: Roof above shaft and floor plan documents.

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:

C. On 10/25/2022 at 9:25am while accompanied by the FOM 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 does not indicate FD #0283, MB-2F-105 within the 6 year inventory and testing. Surveyor observed the listed fire damper number near the 74"x44" sheet metal cover on a 2-hour fire rated shaft. The fire damper number was not accounted for in the inspection report.

Based on observation the facility failed to protect elevator equipment. This deficient practice could result in the elevator power not being shut down prior to sprinkler activation in the event of a fire in the elevator shaft.

Findings include:

A. On 10/25/2022 at 9:10am while accompanied by the CM surveyor observed smoke and heat detectors greater than 2 feet apart and far from the elevator equipment which does not comply with 19.5.3, 9.4, CMS requirements, ANSI A17.1 2007, 2.8.3.3.2 and NFPA 72, 2010 21.4.2.
Locations observed:
1. At 9:10am Elevator #2 machine room
2. At 1:20pm Elevator #6 machine room

B. On 10/25/2022 at 9:12am while accompanied by the CM surveyor observed equipment within the elevator machine room which does not serve the elevator. Location and condition observed Elevator machine room #2 contains a motor control center for the Morgue, Lab and bathroom exhaust fans. The installation does not comply with 8.6.4.2 due to the termination of the hoistway shaft (machine room open to it) contains equipment not related to the elevator hoistways.


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C. On 10/25/2022, at 10:00am while accompanied by the FSM, it was observed that Elevator Equipment Room NEG19N was used as a place for storage of combustible materials not directly related to the function of the space. Therefore, this installation does not comply with Section 9.4.2.2 or ANSI/ASME A17.3 2008 edition, section 2.2.1.


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D. On 10/25/2022 at 8:59 AM while accompanied by FOM, observation revealed the facility failed to provide a heat detector within 2-feet of a sprinkler head in the room occupied by the elevator equipment Room #G225. This condition does not comply with 19.5.3, ANSI A17.1, 2007, 2.8.3.3.2 and NFPA 72, 2010 Edition 21.4.2.

Based on observation, soiled linen, trash chutes and collection rooms are not protected. Trash chute collection rooms are used for purposes not related to the trash chute functions and chutes form unprotected openings between floors. Failure to protect these areas during a fire/smoke event, permits fire/smoke to migrate from one room or area to other floor levels rather than being contained.

The finding is:

On 10/25/2022, at 10:55am while in the company of the CM, it was observed that the third floor linen chute door does not self close to a latched position to comply with 19.5.4. and 8.3.3.3.

Based on document review and staff interviews, the facility failed to provide compliant smoke management systems. This deficient practice could result in the uncontrolled spread of products of combustion during a fire event, which may affect patients, staff and visitors.

Findings include:

On 10/25/2022 at 1:10pm while accompanied by the FD during document reivew documentation was not be provided to demonstrate semiannual testing of the facilities smoke control systems (NFPA 92, 2012, 8.6) for the following:

1 Atrium smoke exhaust system

2. Stairwell pressurization systems

Based on observation and staff interview during the building tour the facility lacks complete protection of the medical gas piping system. Failure to install and maintain this installation could result in failure of the piping system. This deficient practice could affect patients, staff, and visitors.

Findings include:

On 10/24/2022, at 2:15pm while in the company of the FMBG and FSM, it was observed above the 3rd floor ceiling near the centrally located nurses' station in the Classic Building that medical gas system piping is supported by a dissimilar metal not in accordance with NFPA 99-2012, 5.1.10.11.4.2. and not otherwise properly insulated to comply with NFPA 99-2012, 5.1.10.11.4.4.

Based on observation, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

The finding is:

On 10/25/2022 at 1:45pm while accompanied by the CM surveyor's observation determined that critical care patient beds lack electrical receptacles served by normal power as required by NFPA 70 2011 517-19(A).
The location observed: OR#11. Facility representatives stated the same condition existed in OR #12.