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Based on observation during the survey walk-thru, structural components fire proofing was not maintained to provide the required construction rating. This deficient practice could affect patients, staff and visitors if the structural components are compromised during a fire incident.

Findings include: On 3/7/17 at 9:00 AM while in the company of the DRM it was observed that the drywall column enclosure, located on 7th floor, north mechanical room by ACS 16 was breached and the steel column was exposed jeopardizing the structural integrity of this supporting structural member. This does not meet with NFPA 101, 19.1.6.

Based on an observation and interview it was determined that all exits used as a means of egress from an assembly space must be immediately available for exiting. This deficient practice could affect staff and visitors to the facility if the exit doors from the assembly area do not operate properly during a fire emergency.

Findings include: On 3/7/17 at 10:15 AM, while accompanied by the MFM it was determined that in the basement, Cornet Hall is an assembly area that could have an occupant load greater than 100. Based on an observation it was identified that the 4 exit doors leading from this space did not contain panic hardware as required for this occupancy. The lack of panic hardware on each egress door does not comply with NFPA 101, 13.2.2.2.3.

Based on observation, not all exits as means of egress is continuously maintained free of obstructions to full use in case of emergency. This deficiency could affect patients, staff and visitors if the emergency evacuation is through deficient exit.

Finding include: On 3/8/17 at 10:15 AM, while accompanied by ALM, it was determined that in the basement exit stairs No: 2 (S02), is an outside open stair to the first floor. It was observed that a large quantity of puddled water was present at the exit discharge. This location was not installed with a means for removing water from this area. This condition could allow the water to freeze preventing the exit discharge door from opening and cause a slippery condition in exiting. This does not comply with NFPA 101, 19.2.1 and 7.1.10.1.

Based on observation during the survey walk-through, not all egress doors are installed or maintained to permit egress. This deficiencies could affect any staff on the roof or mechanical penthouses because they could be prevented from exiting those areas under emergency conditions.

Findings include: On 3/6/17 at 12:58 PM, while accompanied by the LM, the door into the building from Second Floor Exterior Courtyard 4, which serves as the access point back into the building from the roof and from a series of mechanical penthouses, was observed to be secured against such re-entry as prohibited by 19.2.2.2.4 because the door is keyed both sides.

Based on observation during the survey walk-through, not all corridors are maintained to be clear and unobstructed. These deficiencies could affect patients, staff, and visitors in the area if their egress under emergency conditions could be impeded.

Findings include: On 3/7/17, while accompanied by the LM, it was determined that the following corridor locations were restricted in corridor width, by temporary construction barriers, in a manner prohibited by 19.2.3.4(1) and 7.1.10.2.1. Locations include:

1. 9:30 AM: First Floor, Imaging Department Corridor at MRI Room 1808.

2. 10:08 AM: First Floor, Corridor 1303.

Based on observation during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect patients, staff and visitors in the area if travel to an exit is not clear and does not discharge to the exterior of the building.

Findings include: On 03/07/17 at 9:05AM while accompanied by the LMM, it was observed that the main entry door to the Outpatient Physical Therapy is the only means of egress to an exit. This designated exit path passes through the Lobby area, which does not discharge directly to the outside. The total distance of travel from any point in the Therapy Area, including travel within the designated exit exceeds 100'.
This does not comply with the requirements of NFPA 101, Sections 39.2.4.3 (1) (2).

Based on observation during the survey walk-through, not all egress paths are identified by exit signs as required. These deficiencies could affect patients, staff, and visitors in the area if their egress under emergency conditions could be impeded.

Findings include:

On March 7 and 8, 2017, while accompanied by the facility representatives, it was determined that the following egress paths were not provided with proper "EXIT" signage as required by 7.10.1.1.

1. On 3/7/17 at 10:10 AM: 'EXIT' sign installed on Second floor at Wing 2300 smoke door as an exit from occupied patient room Wing 2100 should be removed or blocked, as Wing 2300 is closed for remodeling and should not be used as an exit. A new sign should be installed pointing to the exit stairs No: 1.

2. On 3/8/17 at 9:40 AM: 'EXIT' sign was not installed at the west end at smoke barrier in Corridor CB 310.



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3. On 3/8/17 at 9:40 AM: First Floor, Atrium Corridor C1714, north end, directing occupants into and through Exit Stair 10.

4. On 3/8/17 at 9:42 AM: First Floor, Corridor S13, west end, directing occupants either toward the west or toward the north.

Based on observation during the survey walk-through, the surveyor finds that not all shafts are enclosed with fire rated construction. This deficiency could affect patients, staff and visitors if a fire were to migrate from one area of the building to another area due to deficient shaft enclosures.

Findings include:

A. On 3/7/17 at 10:38 AM while in the company of the DRM, the mechanical chase located next to the manager's office on 6th floor was not being maintained as a 2 hour shaft enclosure. An unrated door was located in the drywall in the corridor. Behind this door was a 1 ½ hour rated access door that had the cylinder lock removed resulting in an unsealed hole in the door. The current arrangement does not comply with NFPA 101, 8.6.5.

B. On 3/8/17 at 9:20 AM while in the company of the DRM, is a chute room across from the director of imaging office. The room used for accessing the chute opening did not contain a rated door assembly, there was a 9" x 21" hole in the wall where an electrical panel appears to have been removed, and the room was not provided with sprinkler protection. This does not comply with NFPA 101, 9.5.1.4 or 8.7.


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C. On 03/06/17 at 1:30 PM while accompanied by the LMM, on the 7th Floor of the South Building, it was observed that the required opening for the ventilation shaft by the Storage Room across the Patient Room 733 was not fire rated access panel assembly. This does not comply with NFPA 101, 19.3.1.1 and 8.3.4.2.

Based on observations during the survey walk-thru, the facility failed to provide separation between hazardous rooms from the surrounding areas. This deficient practice could affect patients, staff and visitors if a fire would spread without proper fire separation.

Findings include:

A. On 3/8/17 at 8:55 AM while in the company of the DRM, the radiology department contains a large sprinklered x-ray storage room. This room is not rated, the walls were observed to not be complete to the deck above and the doors are not remote. Due to the nature of the x-ray film (cellulose acetate film) the room would need to meet with the requirements of NFPA 40, 4.1.2 and NFPA 13, 21.7.







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B. On 3/6/17 at 1:55 PM, while accompanied by MFM, it was determined that in the basement level, Central Storage "B" west set of double doors, Active door did not latch to the inactive leaf when tested. This does not comply with the requirements of NFPA 101, 19.3.2.

C. On 3/6/17 at 2:00 PM, while accompanied by MFM, it was determined that in the basement level, Bio-Hazard Room set of double doors, Active door did not latch to the inactive leaf when tested. This does not comply with the requirements of NFPA 101, 19.3.2.

D. On 3/6/17 at 2:05 PM, while accompanied by MFM, it was determined that in the basement level, Utility Storage Room door did not latch to the frame when tested. This does not comply with the requirements of NFPA 101, 19.3.2.

E. On 3/6/17 at 2:10 PM, while accompanied by MFM, it was determined that in the basement level, Environmental Storage Room door contained a door closer but the closer was propped open and was not self-closing and was not tied to the buildings fire alarm system. This does not comply with the requirements of NFPA 101, 19.3.2.

F. On 3/6/17 at 2:15 PM, while accompanied by MFM, it was determined that in the basement level, Dietary Storage Room door "B24" was not provided with a means for self-closing. This does not comply with the requirements of NFPA 101, 19.3.2.

G. On 3/7/17 at 9:07 AM, while accompanied by MFM, it was determined that in the basement level, Dietary Storage Room door "B081" was not provided with a means for self-closing. This does not comply with the requirements of NFPA 101, 19.3.2.

H. On 3/7/17 at 9:15 AM, while accompanied by MFM, it was determined that in the basement level, Security Storage Room door "S001" was not provided with a means for self-closing. This does not comply with the requirements of NFPA 101, 19.3.2.

I. On 3/7/17 at 9:25 AM, while accompanied by MFM, it was determined that in the basement level, Soiled Linen Room door did not latch to the door frame when the door closer was activated. This does not comply with the requirements of NFPA 101, 19.3.2.

J. On 3/8/17 at 10:00 AM, while accompanied by MFM, it was determined that in the second floor, Lab area, Histopathology Lab door to the exit corridor was not provided with a means for self-closing. This does not comply with the requirements of NFPA 101, 19.3.2.

K. On 3/8/17 at 10:15 AM, while accompanied by MFM, it was determined that in the second floor, Lab area, room S-277, door to the exit corridor was not provided with a means for self-closing. This does not comply with the requirements of NFPA 101, 19.3.2.

By direct observation the facility failed to enclose the kitchen grease duct within a fire rated enclosure. This deficient practice could result in the uncontrolled spread of fire and products of combustion during a kitchen hood fire event, which may affect patients, staff and visitors.

Findings include:

A. On 3/6/17 at 1:00PM in the company of the LE while touring the roof top penthouses the surveyor observed in the penthouse with the kitchen grease hood exhaust fan that the duct rise from the basement kitchen penetrated the floor without protection and ran horizontally without a rated enclosure as required by NFPA 96, 7.7.1 to the unenclosed exhaust fan.

B. On 3/6/17 at 1:00PM in the company of the LE while touring the roof top penthouses the surveyor observed the connections between the kitchen grease duct and the exhaust fan were made using flexible connectors a prohibited by NFPA 96, 8.1.3.5.

Based on observations during the survey walk-thru, the facility failed to provide documentation that all finishes meet with Class A fire rating. This deficient practice could affect patients, staff and visitors if a fire and smoke were permitted to spread quickly.

Findings include:

A. On 3/8/17 at 8:22 AM while accompanied by the DRM, 2nd floor North, Physical Therapy Department. This suite has a large storage room at the back that contains large quantities of wooden peg board. The quantity and rating does not meet with NFPA 101, 10.2.5.1.

B. On 3/8/17 at 9:10 AM while in the company of the DRM, 2nd floor contains a staff work area with movable fabric coated wall coverings. Due to the quantity and unknown fire rating of this material along the exit corridor it does not meet the requirements of NFPA 101, 10.2.1.4.

C. On 3/8/17 at 9:20 AM while in the company of the DRM, is a chute room across from the director of imaging office. The room used for accessing the chute opening did not contain a rated door assembly, there was a 9" x 21" hole in the wall where an electrical panel appears to have been removed, and the room was not provided with sprinkler protection. This does not comply with NFPA 101, 9.5.1.4 or 8.7.

Based on an observation and interview, the facility failed to install all required initiating devices to provide a properly functioning fire alarm system. This deficient practice could affect patients, staff and visitors if smoke was not detected and the fire alarm system does not operate properly due to smoke detector placement.

Finding include: On 03/07/17 at 9:34 AM, while accompanied by LMM, it was determined that this Outpatient Physical Therapy contained several smoke detectors that were located less than 3-feet from a mechanical supply vent. NFPA 101, 9.6, NFPA 70 and NFPA 72, 17.7.3.1.

Locations observed include:

1. Supply Room
2. Break Room
3. Staff Record Room

Based on observations, the facility failed to provide visual alarms throughout the facility. This deficient practice could affect patients, staff and visitors if the failure to install a complete fire alarm system hinders notification to occupants.

Findings include: On 3/7/17 while accompanied by the DRM, "on-call rooms" were observed to not contain visual alarms (strobes) as required by NFPA 72, 18.5.4.6.

1. 1:10 PM, 4th floor south, paramedic on-call rooms.

2. 2:00 PM, 3rd floor center, resident surgery on-call.




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3. 9:00 AM, 2nd floor, Operating Suite, PACU, on-call sleeping room.

Based on observation during the survey walk-through, not all portions of the building's fire alarm control system are installed and maintained as required. These deficiencies could affect any patients, staff, or visitors in the building because the fire alarm system could be inadvertently turned off.

Findings include: On 3/6/17, while accompanied by the LM, circuits serving fire alarm system NAC Panels were observed that are not labeled "FIRE ALARM" as required by NFPA 72 2010 10.5.2.2, are not provided with red marking as required by NFPA 72 2010 10.5.2.3, and are not provided with a listed breaker locking devices as required by NFPA 72 2010 10.5.2.4.

1. 1:13 PM: Second Floor, Electrical Panel 2SL2, located in Electrical Closet 2500, Circuit 5.

2. 2:40 PM: Second Floor, Electrical Panel LS2A, located in Electrical Closet 2902, Circuits 2 and 5.

Document review and facility staff interview of inspections, testing and maintenance records required are not maintained at an approved location for the life of the fire protection system. Failure of the fire alarm system to operate correctly will jeopardize all occupants of the building during a fire emergency.

Findings include: On 03/07/17 at 10 AM, while accompanied by LMM, it was determined that during a staff interview and document review process, the surveyor identified that records were not available to show maintenance and testing of the fire alarm system, fire sprinkler system and other devices as required by NFPA 25, NFPA 70, National Electric Code and NFPA 72.

Based on observation, not all areas are provided with sprinkler protection. This deficient practice could affect patient, staff and visitors if the failure to install the sprinkler systems in accordance with code requirements can compromise the level of protection required to be provided.

Findings include:

A. On 3/7/17, at 10:20 AM while accompanied by DRM, a sprinklered storage room on the 6th floor by room 633 contained several unsealed conduits that penetrate the ceiling tiles. The sprinkler protection, does not comply with NFPA 13, 8.15.10.3.

B. On 3/7/17, at 11:00 AM while accompanied by DRM, a sprinklered storage room on the 5th floor electrical closet contained several unsealed conduits that penetrate the ceiling tiles. The sprinkler protection, does not comply with NFPA 13, 8.15.10.3.

Based on observation during the survey walk-through not all portions of the facility's automatic sprinkler system are properly installed and maintained. This installation could affect patients, staff, and visitors if the sprinkler system activation is delayed by not having the sprinkler heads located within the heat capture zone.

Findings include:

A. On 03/07/17 at 9:30 AM, while accompanied by the LMM within the Therapy Gym, the surveyor finds the installation of the sprinkler heads to be more than 12 inches from the exposed deck above. This does not comply with NFPA 101 2012 39.4.2.1 and NFPA 13 2010.

B. On 03/07/17 at 9:35 AM, while accompanied by the LMM within the Therapy Gym, the surveyor observed the 6 skylights with approximate size of 8 feet x 8 feet x 6 feet in depth lacked sprinkler protection. This does not comply with NFPA 13 2010 Sections 8.5.7 and 8.5.7.1
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Based on observation during the survey walk-through, the facility failed to install and maintain automatic sprinkler protection in accordance with the code. Lack of maintenance for fire protection system could affect patients, staff and visitors if a delayed response of those systems lacked the required protection.

Findings include: On 3/7/17, at 2:20 PM while accompanied by DRM, a supply closet on the 4th floor across from the center mechanical room contained storage of supplies within 18" of the sprinkler head. This does not comply with NFPA 13, 8.7.6.

Based on observation during the survey walk-through, not all fire extinguishers are installed and maintained as required. These deficiencies could affect patients, staff and visitors in the immediate area if the fire extinguishers failed to operate as required.

Findings include: On 3/7/17 , while accompanied by the LM, Type K fire extinguishers were observed in commercial cooking environments, which lack placards required by NFPA 10, 5.5.5.3 The following locations were identified.

1. 1:00 PM: First Floor, Servery Corridor C1034.

2. 1:32 PM: Basement, Kitchen B136.

Based on observations and interviews the facility failed to provide exit access corridors properly separated from use areas as required. This condition may expose patients, staff, or visitors in the area to a fire emergency if the area is not manned 24 hours and or not sprinklered by compromising the facility's exit access corridors.

Findings include: On 03/06/17 at 2:00PM, while accompanied by the LMM, on the 7th Floor (non-sprinklered floor) of the South Building, it was observed that the Outpatient Prep/ Holding, contained spaces opened to the corridor, which are not manned 24 hours but provided with smoke detection. This does not comply with NFPA 101, section 19.3.6.1 Exception No. 1 (b) (c).

Locations include:

1. Ambulatory Surgery Waiting Area
2. Nurses' Station (not staffed 24/7)
3. Copy/Printer in Alcove

Based on observation during the survey walk-thru and review of the facility's life safety reference drawings, Corridor doors are not properly installed to latch. This deficient practice could affect patients, staff and visitors if failure of the corridor doors and the means of keeping the door closed compromises the means of egress corridor intended to provide a protected path of egress to an exit.

Findings include: On 3/7/17 at 10:20 AM while accompanied by DRM, a sprinklered storage room on 6th floor by room 633 contained a double leaf door from the corridor. The secondary leaf contained a manual flush bolt that was not engaged at the time of this survey. The doors did not meet with the latching corridor door requirements of NFPA 101, 19.3.6.3.5.

Based on observation during the survey walk-through, not all smoke barrier walls are constructed and maintained as required. These deficiencies could affect patients, staff, and visitors in the adjacent smoke compartments if smoke was to pass between them.

Findings include:

A. On 3/7/17, while accompanied by facility representatives it was determined that the following locations at smoke barrier walls contained pipe or other penetrations are not sealed against the passage of smoke as required by 19.3.7.3 and 8.5.6.2.

1. 10:30 AM: Smoke barrier between exit corridors C2100/2133, adjacent to Room 2301.
2. 11:10 AM: Smoke barrier at the exit corridor at Patient Sleeping Room 2192 wall was not sealed to the metal decking.
3. 11:20 AM: Smoke barrier at the exit corridor2121A adjacent to Patient Sleeping Room 2192.
4. 12:45 PM: Conference room 'C', east smoke barrier wall.
5. 1:10 PM: Smoke barrier above the smoke door between room #s 1292 and 1293E.




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6. 1:32 PM: Smoke barrier adjacent to Patient Sleeping Room 2509.
7. 1:49 PM: Smoke barrier adjacent to Patient Sleeping Room 2501.
8. 2:40 PM: Smoke barrier adjacent to Exit Stair 7.

B. On 3/6/17 at 1:50 PM, while accompanied by the LM, a smoke barrier wall was observed, adjacent to Patient Sleeping Room 2501, at which drywall joints are not taped and mudded above the ceiling as required by 19.3.7.3 and 8..5.2.2.

Based on observation, the facility failed to provide windows in all patient rooms in accordance with code requirements. This deficient practice could affect patients, staff and visitors if a lack of installed windows hampered fireman from external rescue.

Findings include: On 3/8/17 at 10:35 AM while accompanied by DRM, during the tour of the Intensive Care Unit (ICU), it was noted that most of the patient rooms do not contain a window to the exterior. This is a requirement by CMS, 42 CFR 482.

Based on observation, the facility failed to maintain the piping in accordance with code requirements. This deficient practice could affect patients, staff and visitors if failure to install and maintain the piping systems leads to failure of the system to perform as required by code.

Findings include: On 3/7/17 at 11:14 AM while accompanied by DRM, on the 5th floor center / south cross corridor doors by the exit door, a copper medical gas pipe was observed to be in direct contact with a sprinkler pipe. This is not permitted based on NFPA 99, 5.1.10.11.4.

Based on observation, the facility failed to maintain the electrical system in accordance with code requirements. This deficient practice could affect patients, staff and visitors if failure to install and maintain the electrical system leads to electrical hazards or failure of the system to perform as required.

Findings include:

A. On 3/7/17 at 10:22 AM, while accompanied by DRM, it was observed that the 6th floor clean utility room contained mobile equipment. The mobile equipment was placed in front of the electrical panel. The arrangement does not meet the requirements of NFPA 70, 110-2(a), 110.32 or NFPA 99, 6.3.2.1.



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B. On 3/8/17 at 8:30 AM, while accompanied by MFM, it was determined that in the second floor, Surgery Suite, Operating room #3 did not contain a normal power outlet. This does not comply with the requirements of NFPA 99, section 6.3.2.2.1.2.

C. On 3/8/17 at 8:45 AM, while accompanied by MFM, it was determined that in the second floor, Surgery Suite, PACU area did not contain a normal power outlet at 8 of the recovery bays. This does not comply with the requirements of NFPA 99, section 6.3.2.2.1.2.

C. On 3/8/17 at 8:50 AM, while accompanied by MFM, it was determined that in the second floor, Surgery Suite, PACU isolation room did not contain an emergency power outlet. This does not comply with the requirements of NFPA 99, section 6.3.2.2.1.2.