HospitalInspections.org

Based on random observation, during the survey walk-through, the building construction type does not comply with 19.1.6.2. including any exceptions. This condition may affect patients, staff, and visitors within the upper floors of the building during a fire event.

A. Morning of May 16th, Room # 8470 the surveyor observed exposed steel roof construction to determine that the building construction type is Type II (000). Although the building is sprinkler protected the building's story height does not allow for unprotected steel members.
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Based on random observation during the survey walk-through on May 15, 2012, not all interior finishes comply with applicable requirements of the Life Safety Code. These deficiencies could affect all patients in the facility, 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. Wood paneling wall finishes and framing was observed in the 1st floor St. Anthony's Shrine room that could not be confirmed to conform to Class A, B, or C in accordance with 19.1.6.3, 19.3.3.2 and 10.2.3. Although the room is sprinkler protected and the door to this room was observed to be a 'B' label fire door, the enclosing walls were not confirmed to provide a fire resistance rated assembly. (An access door in the corridor wall accesses areas behind the backlit stained glass.) The space was not provided with smoke detection as an additional protective feature.

B. Data room 1423 contained painted plywood and unfinished drywall that could not be confirmed to conform to Class A, B, or C in accordance with 19.3.3.2 and 10.2.3.
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Based on random observation during the survey walk-through on May 15, 2012, 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 smoke compartment, as well as any staff and visitors present, because the lack of protection could result in smoke compromising the facility's exit access corridors.

Findings include:

A. The Ground floor storage closet at G327A is provided with bi-fold doors which are not resistant to the passage of smoke in accordance with 19.3.6.1 and therefore this space is considered to be open to the corridor. The Closet G327A lacked sprinkler protection, but the alcove directly adjacent was sprinklered to provide coverage. The Closet G327A was not provided with smoke detection to comply with 19.3.6.1 Exception No. 1 (c).

B. Two greater-than-32-gal. trash containers were stationed in the corridor outside Respiratory Therapy office G436 in non-compliance with 19.7.5.5.


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Based on random observation, during the survey walk-through, use areas in corridors (or open to corridors) do not comply with 19.3.6.1. exception 1. This condition may affect patients, staff, and visitors within the adjacent egress corridor during a fire emergency.

C. May 15th at 11:10am 4th floor Work area 4314 (which is greater than 64 square feet) was observed open to the corridor further it is not located to permit direct observation by staff and is not smoke detected to comply with 19.3.6.1, Exception 1.
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Based on random 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 within the smoke compartment, 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. Based on observations it was determined that the facility failed to maintain the closure for corridor doors. NFPA 101, 2000. 19.3.6.3.2. Findings include:
1. On 5/15/12 at 11:02 AM, observations determined that the clean utility Room (2303), door contained an unapproved hold open device. The door to the corridor was equipped with a foot peg which would not permit the door to close with the activation of the fire alarm.


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B. The double egress cross corridor doors defining the boundary of the 1st floor Office Suite west of the main entry also form a smoke barrier wall. The doors did not close completely to form a barrier to smoke due to air pressure relationships to comply with 19.3.6.3.2 and 8.3.4.1.

C. The east pair of doors from the Kitchen were not positive latching to comply with 19.3.6.3.2. (The doors were equipped with manual flush bolts and an astragal without a coordinator.)

D. The west pair of Kitchen doors (27209?) did not close to a latched condition under fire alarm testing.
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Based on random observation during the survey walk through 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. This condition could affect all patients, staff and visitors on two floor levels.


A. On the morning of May 15, 2012, the 8th floor Chute rooms 8498 and 8465 were observed to have both chute access doors in both rooms that did not latch to the closed position.


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Based on random observation during the survey walk-through on May 15, 2012, not all stairs ventilation shafts and/or pipe shafts 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:

B. Based on random observation during the survey walk-through, not all stair or shafts are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 2000, 19.3.1.1 and 8.2.5.
1. On 5/15/12 at 11:10 AM, observations determined that the Storage Room (2301 B), contains a 2 hour rated shaft. The door to the shaft was not self closing to a latched position.


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C. The access door for the dumbwaiter shaft located in the Ground floor Kitchen was observed not to be self-closing to a latch condition and was left open. The door did not maintain the required fire resistive rating for the shaft to comply with 19.3.1.1.


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D. At 1:21 PM on May 15, 2012, a series of pipe penetrations through the 2 hour fire rated floor assembly, in the pipe chase between Fifth Floor Soiled utility Room 5409 and Women's Toilet room 5450, were observed to not be sealed against the passage of fire in accordance with 8.2.3.2.4.2.


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E. Main Building - 3rd Floor: The access door for the ventilation shaft T3058 located in the Corridor 3480 was observed not to be fire rated to comply with 19.3.1.1 and 8.2.3.2.3.1

F. Main Building - 3rd Floor, Shaft T3066- A duct located in the corner of this shaft is partially engaged in the wall construction. A fire barrier to properly separate the shaft to comply with 19.3.1.1 and 8.2.5.4 could not be confirmed.

G. Main Building - 3rd Floor. Dutwork was observed located in the Mechanical Room 3451 which appears to penetrate uppers floors and below and not provided with fire dampers to comply with 8.2.3.2.4.1. NFPA 90A 1999 3-3.1.1. The Life Safety drawings do not indicate a fire separation in this Room. It was also observed that this same room is being used to store paint materials, etc.
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Based on random observation, during the survey walk-through, exit discharge signage is not present within the stairways. This condition may affect patients, staff, and visitors for a safe means of egress to a discharge during a fire emergency.

A. May 16th at 9:10am Surveyor was unable to locate signage within a stair enclosure that identifies the story, the top and bottom terminus, and the stair enclosure identification to comply with19.2.10.1, 7.10 and 7.2. Location observed: 4th floor landing of Stair 4022.
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Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 18.3.7.5., 18.3.7.6., and 18.3.7.7. These deficiencies could affect any patients, staff, or visitors on each building story on which this condition exists by permitting smoke to pass between adjacent smoke compartments.

Findings include:

A. Doors in smoke barrier walls were observed, during a test of the building fire alarm system held on the afternoon of may 17, 2012, at which magnetic hold-open devices were observed not to release as required by 18.3.7.6. This condition was observed at the Fourth Floor but is understood to exist throughout the building. Locations observed include:

1. Pair of doors between Corridor C4-9304 and Corridor C4-9305.

2. Pair of doors between Corridor C4-9401 and Corridor C4-9403.

3. Pair of doors between Corridor C4-9402 and Corridor C4-9301.
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Based on random observation during the survey walk through, not all hazardous areas are separated from the remainder of the building to comply with 19.3.2.1. Sprinklered Hazardous Areas are not properly separated in accordance with 8.4.1. This condition may prevent staff and visitors within the means of egress against safe passage to an exit discharge.

Findings include:
A. On 5/15/12 at 10:35 AM, observations determined that the soiled utility Room (2325) door does not close and latch to the door frame with the automatic door closer. NFPA 101, 2000 Edition, 8.2.3.2.3.1(2).
B. On 5/15/12 at 10:35 AM, observations determined that the soiled utility Room (2325) contains 4 abandoned wall pipe penetrations that are not sealed to maintain the wall rating. NFPA 101, 2000 Edition, 8.2.3.2.4.2.


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C. The Ground floor Copier room G368 containing paper storage was observed to have a self-closing door equipped with a hold-open feature which was not otherwise activated by the fire alarm system.


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D. Main Building - On 05/17/12 1:30PM, 3rd Floor : Designated Storage Room T3077 is not separated from the corridor. Life safety drawings do not indicate this storage to be a hazardous area but it is not separated from the corridor due to the opening by the Work Area T3074 and Nurse Station T3072. This room contains shelves with equipment and other materials and does not comply with 19.3.2.1 (7) and 8.4.


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E. On May 16th 8:15am, the 4th floor room 4519 corridor door of a deemed hazardous area (life safety floor plan reads classroom however being used as equipment storage) contains a manual hold open device which prevents the door from being self closing and does not comply with 19.3.2.1

F. On May 16th 9:15am, the 4th floor storage room 4501 corridor door contains a manual hold open device which prevents the doors from being self closing and does not comply with 19.3.2.1
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Based on random observation during the survey walkthrough 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.

A. On 05/15/12 at 2:00pm 3rd floor West Stair C3100, The Life Safety plans indicate that the identified Shaft T3160 is part of the 2-hour stair enclosure and not separated from the stair and does not comply with 19.3.1.1.
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Means of egress components are not constructed in accordance with 7.2. These deficiencies could affect all persons required to utilize the means of egress component.

Findings include:

A. The ramp provided at 1st floor corridor T1033 was not provided with handrails to comply with 7.2.5.4.
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Based on random observation during the survey walk through not all exit accesses are arranged so that exits are readily accessible at all times to comply with 7.2.2.4.1. This condition could affect all patients, staff and visitors on two floor levels.

A. On the afternoon of May 15, 2012, the West Stair exit discharge was observed not to provide a clear identifiable path which is able to be maintained under all seasonal weather conditions that leads to a public way.
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All inside stairs serving as an exit or exit component shall be enclosed in accordance with NFPA 101, 2000, 7.1.3.2.
Findings include:
A. On 5/15/12 at 11:00 AM, observations determined that the window from the South Stair (by turret)is exposed by other parts of the building at an angle of less than 180 degrees that are non-rated and within 10 ' -0 " which is not permitted based on NFPA 101, 7.2.2.5.2.


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Fire separation barriers are not maintained in accordance with 19.1.2.3 and 8.2.3. 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 different occupancies.

Findings include:

B. The 1st floor 2-hour barrier doors 27215 between the Main Hospital building and the Chapel building were observed to have a pair of doors which could be opened in a sequence that would not allow them to return to the closed and latched condition due to the latch bolt and strike plate arrangement provided on the doors. An arrangement similar to the doors at Stair T1031 appeared to be required.

C. The Ground floor 2-hour barrier doors 72172 which access the Tunnel did not close to a latched condition.

Based upon review of the facility's life safety plans and observation during the survey walk-through, horizontal exits do not comply with 19.2.2.5 and 7.2.4. This deficiency could delay the access to an exit and the activation of the fire alarm in multiple fire/smoke compartments and affect patients, staff and visitors.

Findings include:

D. The plans indicate that a horizontal exit exists on the Ground floor between the Main Hospital building and the CH building. However, horizontal exits do not exist on other floors of the building which provide a separation continuous to ground in accordance with 7.2.4.3.1.

E. The plans do not indicate and it was not observed that manual fire alarm pull stations exist on each side of all designated double egress horizontal exits (or designated 2-hour fire barriers which could be considered as meeting the horizontal exit requirements) to comply with NFPA 101, 9.6.2.3 and NFPA 72, 2-8.2.2.

1. Main Building - 3rd Floor - Designated 2-hour fire rated occupancy separation exit doors between Corridor T3048 and Corridor T3047 lack a manual pull device on the Business Occupancy side to comply with 9.6.2.3 and NFPA 72, 2-8.2.2.


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Based on random observation during the survey walk through not all exits contain a manually operated fire alarm box to comply with 9.6.2.3. This condition may affect all patients staff and visitors within in smoke/fire compartments and delay the notification of a fire condition.

Findings include:

F. May 15th 1:30pm 4th floor The designated 2-hour fire barrier separation between Childrens Hospital Building and the Main Building at a pair of cross corridor doors lack manually operated pull stations.
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Based on random observation during the survey walk-through, not all exit discharge locations are provided with illumination to comply with NFPA-101, Sections 18.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe access to the public way.

A. On the morning of May 15th, West SPD exit discharge contained no light fixture to comply with 7.9.1.2, for lighting to be of instantaneous operation so as not to leave the exit path in darkness.
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Based on random observation during the survey walk through, failure to maintain the emergency lighting system could result in the lack of illumination for a path of egress. This could affect all patients, staff and visitors during a fire event. The installation does not comply with 39.2.9.

A. On the afternoon of May 15, 2012, the battery operated emergency corridor light did not work when tested.
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Based on random observation during the survey walk-through on May 15, 2012, exit signs were not fully visible to designate the path of egress in all cases in accordance with 18.2.10.1. 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 utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. The exit sign in the CH building north corridor, east side of the smoke barrier doors was obstructed by a mirror ball in non-compliance with 7.10.1.7.
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Based on random observation during the survey walk through failure to maintain a central station for the reporting of emergency situations does not comply with NFPA 72. This condition could result in the delayed response to an emergency rescue situation during a fire event. This condition may affect all patients staff and visitors.


A. Morning of May 16th, Level H (Helipad) Stair 8, the rescue assistance intercom does not report to a 24 hour location. It was determined that there was no active, dedicated central station assigned for rescue assistance. Therefore the intercom system in all stairs did not report to a central station. Signs were posted within the stairwells which read that the intercom was out of service. This does not comply with 18.2.2.10 and 7.2.12.2.5.


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A fire alarm system with approved components, devices or equipment is not installed according to NFPA 72, National Fire Alarm Code, to provide effective warning and to direct staff to the source of the fire.

Findings include:

B. On 5/16/12 at 9:20 AM, during the facility walk through and direct observation on 1st floor, in the corridor near exit sign (278089) the smoke detector was located within 3 ' -0 " of the supply air which does not meet the requirement of NFPA 72 (1999) 2-3.5.1.

C. On 5/16/12 at 10:40 AM, during the facility walk through and direct observation on 1st floor, Microbiology Lab (by the TB Lab) the smoke detector was located within 3 ' -0 " of the supply air which does not meet the requirement of NFPA 72 (1999) 2-3.5.1.

D. On 5/17/12 during the fire alarm tests, cross corridor doors failed to close during the activation of the fire alarm at the 1st floor, cross corridor doors C1-9412.
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Based on document review, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. This deficiency could affect any patients, staff, or visitors in the building because fire alarm system components may not be operational.

Findings include:

A. Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis as required by NFPA 72 1999 Table 7-3.2. During the review of records in the Milestone Building First Floor Gandhi Meeting Room on the morning of May 17, 2012, it was determined that a smoke detector in Patient Sleeping Room 7341 in the Main Hospital Building was not tested by the outside vendor during the system test conducted on December 30, 2011. No records were available which indicated that the device had been subsequently tested.
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Based on random observation during the survey walk through the failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed action during a fire event. The sprinkler system is not installed to comply with NFPA 13. This condition may delay activation of the fire alarm system and affect all patients, staff and visitors.

A. Afternoon of May 15th, Ground level room G004, surveyor was not able to view sprinkler heads within this room. There does not appear to be adequate sprinkler coverage for this area.

B. Afternoon of May 15th, Ground level inspector test room (across from G004) is not sprinkler protected.


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Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999).

Findings include:

C. Sprinkler head placement was observed not to be in accordance with NFPA 13-1999, 5-6.4.1.

1. The sprinkler head at Electric 2135 was located greater than 3' below the deck above.

2. The sprinkler head and smoke detection devices at Storage room 2125 were not located at the high point of the space.


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Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999), NFPA-20(1999), and NFPA-70(1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

D. The fire pump room does not have a battery operated emergency light as required by NFPA 20-2-7.4.

E. The transfer switch for the fire pump is not located at the pump location as required by NFPA 20-6-6.4.


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Based on random observation during the survey walk through the failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed action during a fire event. This condition may delay activation of the fire alarm system and affect all patients, staff and visitors.

F. May 17th 8:50am4th floor, Mechanical room #4029 contains multiple duct work exceeding 48 inches in width which lack sprinkler protection below. Example locations 55 inch wide duct southwest corner of room approximately 3'-6" above the floor and duct located above AHU # 12.


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Based on random observation during the survey walk-through on the morning of May 15, 2012, not all portions of the facility's sprinkler stand pipe system are installed in accordance with NFPA 14 2000.

Findings include;

G. During the survey tour of the south stairway on 5 th floor a stand pipe was observed without a 3 1/2 " gauge installed at the top in accordance with 3-6.1.

This deficiency could cause injury to patients or staff due to fire department connecting a hose to a un-pressurized stand pipe.
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Based on random observations during the survey walk through and staff interview, not all portions of the sprinkler system are maintained in accordance with NFPA 25 1998 2-2.1.1 insuring the reliability and proper operation of all elements .

Findings include:

A. CH Building - 3rd Floor, Illinois Neurological Institute Unit: On 05/15/2012 at 10:30 AM, while accompanied by the corporate facility staff member observations determined that the sprinkler system is not maintained to be fully operational due to sprinkler heads that were coated with dust.
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Based on direct observation and document review and staff interview, the facility failed to provide:

a. The four required alarm points for 4 of 4 fire pumps on the remote alarm annunciators at a point of constant attendance. (NFPA 20, 1999, 7-4.7)

b. Indication that alarm conditions were simulated at the time of the annual fire pump test. (NFPA 25, 1998, 5-3.3.3)

c. Indication that the annual flow tests for 4 of 4 fire pump were conducted under emergency power. (NFPA 25, 1998, 5-3.3.4)
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Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A 1999. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke and fire to pass between building stories.

Findings include:

A. At 11:15 AM on May 15, 2012, a duct was observed, which penetrates the floor in Fifth Floor Mechanical Room 5241, for which the fire damper is not in the plane of the floor as required by NFPA 90A 1999 3-3.2.

B. At 11:19 AM on May 15, 2012, the following conditions were observed relative to a duct which penetrates the 2 hour fire rated wall between Fifth Floor Mechanical Room 5241 and Corridor T5602:

1. The duct penetration was observed to lack a fire damper required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1.

2. The duct penetration was observed to not be sealed against the passage of fire in accordance with a tested design as required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.1. because a large gap exists between the duct and the wall.


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C. On the afternoon of May 16, 2012, during the survey tour of the CH building mechanical penthouse, two Air Handling Units were observed without supply or Return smoke detection in accordance with 4-4.2.

This deficiency could cause injury to patients and staff due to the undetected spread of smoke.

D. During the record review process it was discovered the facility did not have building ventilation drawings to show the location of fire and smoke dampers in accordance with 3-4.6.1.

This deficiency could cause injury to patients and staff during an emergency situation to isolate part of the building.
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Based on random observation during the survey walk-through, Kitchen exhaust hoods are not constructed and maintained in accordance with 9.2.3, 19.3.2.6 and NFPA 96-1998. These deficiencies could affect all persons in the smoke compartment by exposing occupants to fire and smoke conditions resulting from a fire under the hood system.

Findings include:

A. The Cafeteria Serving Line exhaust hood was observed not to have tight fitting filters installed in compliance with NFPA 96-1998, 3-2.3.

B. The ceiling tile adjacent the hood was displaced allowing heat and/or vapors to ascend above the ceiling tile system where contamination of the above ceiling cavity can occur.

C. The automatic shut-off of gas and electric power to the equipment under the hood could not be confirmed to comply with NFPA 96-1998, 7-4.1. The location of the gas valve and/or electric shunt-trip(s) were not readily available.

D. The manual activation devices for the two (2) Kitchen hood suppression systems were located on the wall adjacent the hood systems and not along the path of exit to comply with NFPA 96-1998, 7-5.1. Both were located on the opposite side of the hood from the exiting path.
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Based on random observation during the survey walk through not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

A. 6th floor, Bridge contain multiple beds, one gurney and one reclining chair stored in this location.
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Based on observation and staff interview, it was determined that facility failed to provide soiled linen or trash collection receptacles not exceed 32 gal in capacity in accordance with NFPA 101, 2000 Edition, Section 19.7.5.5. and 19.3.2.1. Findings include:
A. On 5/16/12 at 10:15 AM during the onsite survey of the treatment suite it was determined that the men ' s locker (1-9425A) exceeded the 32-gallon maximum. The room contained a 2 - 32 gallon soiled linen receptacles and a 32 gallon trash receptacle in a 64 square foot location.
B. On 5/16/12 at 10:20 AM during the onsite survey of the treatment suite it was determined that the women ' s locker (1-9229B) exceeded the 32-gallon maximum. The room contained a 2 - 32 gallon soiled linen receptacles and a 32 gallon trash receptacle in a 64 square foot location.
C. On 5/16/12 at 10:25 AM during the onsite survey it was determined that the Staff lounge (1-9235) exceeded the 32-gallon maximum. The room contained 2 - 54 gallon trash receptacles in a 64 square foot area.
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Based on random observation during the survey walk through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. On 5/16/12 during the walk-through of the surgery suite (G9456) Medical gas tanks were observed being stored in a sprinkler protected room. The size and number of tanks in this room may exceed 3000 cu ft, the room does not meet storage requirements of NFPA 99, 1999, 4-3.1.1.2 and / or 8.3.1.11.1.


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Based on random observation during the survey walk-through on May 16, 2012, not all portable medical gases are stored in accordance with NFPA 99. This deficiency could affect all occupants of the smoke compartment they are located in because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials.

Findings include:

B. The 3rd floor Medical Gas storage room 3-9453 was observed to have the automatic flush bolts on the 45 minute rated inactive corridor door leaf not engaging.
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Based on random observation during the survey walk through the medical gas system is not maintained to comply with NFPA 99 1999. This condition may affect all patients and staff within the facility.

A. On the afternoon of May 15, 2012, The medical gas manifold room contains a low return to the inside truck dock. The grille was blocked by boxes and supplies.
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Based upon random observation during the survey walk-thru on the morning of May 16, 2012, the emergency power system is not installed in accordance with NFPA 70 and NFPA 99. Non-compliance could result in inability to identify the location of system components to diagnose failures of the emergency power when required.

Findings include:

A. Emergency power electrical receptacles located in the 3rd floor typical Operating Rooms (#12 & #14 observed) are not labeled to identify the circuit and panel from which they are fed to comply with NFPA 70-1999, 517-19a.

B. Emergency power electrical receptacles located in the 2nd floor Patient Holding 2129 are not labeled to identify the circuit and panel from which they are fed to comply with NFPA 70-1999, 517-19a.
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A. Based on observation the facility failed to protect patients, visitors and staff from contact with hot water and drain pipes exposure by installing insulation or protective panels at all sink locations as required by ADA and the Illinois Accessibility Code 400.310(m)(6). Findings include:
1. 1-9317 - Restroom
2. 1-9408 - Restroom
3. 1-9410 - Restroom
4. 1-9452 - Restroom


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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

B. 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.
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Based on random observation during the survey walk-through 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.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches. Examples include the elevator room panel EPA, (equipment branch?), serves all of the cab lighting that should be served from the life safety panel, and panel L1A a life safety panel serves the security camera and receptacles that should be fed from a critical panel. These examples and other locations throughout the building do not meet the requirements of NFPA-70, Section 517-31 thru 35.
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Based on random observation during the survey walk-thru on the morning of May 16, 2012, electrical wiring and equipment was not installed and maintained in accordance with NFPA 70 National Electric Code and NFPA 101, 9.1.2. These deficiencies could result in exposure of occupants to electrical shock.

Findings include:

A. Electrical panel C31 located in Electrical room 3115 (Surgery) was observed with an open breaker space missing complete enclosure to comply with NFPA 70-1999, 384-18.
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Existing elevators are not confirmed to be equipped with Firefighter's Service in accordance with ASME/ANSI A17.3 - 3.11.3 and A17.1 - 211.3. Failure to provide required services could endanger occupants of the elevator and prevent firefighters' use of the elevator(s) when needed.

Findings include:

A. The Ground floor level of Elevator #16 was not confirmed to have smoke detection provided for the elevator recall system. Detection was provided in the corridor, but not near the elevator door and not confirmed to interface with the elevator recall system.
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Based on random observation during the survey walk through, 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 disconnect on elevator 30 and 31 for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.
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Based on random observation during the survey walk through, 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 observed that the elevator machine rooms for all elevators 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.

B. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.
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Based on random observation during the survey walk through, 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 observed that the elevator machine rooms for elevators 1, 2, 3, 4, 5, 6, and 7 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.

B. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.
.

Based on random observation during the survey walk through, 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 observed that the elevator machine rooms for elevators 20, 21, 22, and 23 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.

B. The surveyor did not find a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53. NFPA-99, Section 3-4.2.2.2(b)6 requires these disconnects to be served from the Life Safety branch of the emergency power system.
.