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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.

Findings include:

On July 22, 2025, at 11:45am while in the company of the DFS, FSOM, and SFSM it was observed that the top section of stair 6 lacked guard railings that restricted passage of a 4" sphere to comply with 7.2.2.4.5.3. The horizontal separation between the stair runs is greater than the 12" permitted by CMS for approved existing stairs to permit open guards.

Based on observation illumination of the exit discharge portion of the means of egress is not provided to maintain illumination as required. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On July 22, 2025 at 3:30pm, while in the company of the DFS, FSOM, and SFSM it was observed that exit discharge lighting was not installed at the exterior exit from exit passageway 1398. This does not comply with 19.2.8, 7.8.1.3

Based upon observation, vertical openings between floor levels are not protected in accordance with Code requirements. Failure to protect vertical openings between floor levels can permit the affects of a fire/smoke condition to migrate to other floors to compromise the safety of patients, staff and visitors.

Findings include:

On July 22, 2025, while in the company of DFS, FSOM, and SFSM, it was observed that fire rated access doors located in stairway shafts were not self closing and self-latching to provide full enclosure and separation of the shaft to comply with 19.3.1, 8.6, and NFPA 80. Locations observed include:

A. The door serving stair 1 on the 4th floor observed at 12:20pm.

B. The door serving stair 5 on the 3rd floor observed at 1:35pm.

C. The door serving stair 6 on the 2nd floor observed at 2:50pm.

D. The double door serving stair 1 into room 1398, an exit passageway, on the 1st floor observed at 3:30pm. The door assenmbley is equipped with an astragal, but no coordinator was observed to prevent conflict with the astragal and allow for proper closure of both leaves.

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.

Findings include:

On July 22, 2025, at 3:00pm while in the company of DFS, FSOM, and SFSM, it was ovserved that room 2130 was used for storing quantities of combustible material and lacked a self-closing/self latching door assembly to comply with 19.3.2.1.3.

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.

The finding is:

On July 22, 2025, while in the company of the DFS, FSOM, and SFSM, it was observed that sprinkler protected interior spaces are not maintained to prevent the passage of smoke. Failure to maintain smoke tight construction will allow heat, smoke, and products of combustion to bypass to sprinkler heads, which will delay effective operation of the sprinkler system. This does not comply with NFPA 13 2010, 8.6.4.1.1.

Locations include:

A. At 12:05pm, it was observed in stair 5 on the 5th floor that ceiling tile was not cut to fit around 2 pipe penetrations through the suspended ceiling above.

B. At 12:30pm, it was observed in corridor 4020 that the ceiling terminates at cross corridor door framing and that gaps exist between the suspended ceiling systems and glass transoms within cross corridor door framing. The ceiling cavity is exposed on both sides of the frame.

Based on document review and staff interview the facility failed to provied proof of testing of HVAC fire sfety devices. Faillure of protective devices during a fire event risk safety of patients, staff and visitors.

The finding is:

On July 22, 2025, at 4:15pm in the company of the DFS, FSOM, and SFSM review of the documents for the facilities fire/fire smoke damper testing was available for review. The testing was performed within the required 6 year interval. However, during staff interview FSOM indicated that there are approximately 20 fire/smoke dampers that require corrective measures. No subsequent documentation was available at the time of the survey to indicate corrective actions had been made to comply with NFPA 90A-2012, 5.4.8 and NFPA 80-2010, 19.4.9.1.

Based on observation, the facility failed to install and maintain the electrical and medical gas piping systems as required. This deficient practice could affect patients, staff and visitors because a failure of the electrical system could result in failure of the system or electric shock.

The finding is:

A. On July 22, 2025, at 12:00pm while in the company of the DFS, FSOM, and SFSM it was observed above cooridor 5150 that the medical gas pipe installation is supported by ductwork and in contact with dissimilar metals and therefore not supported as required by NFPA 99-2012, 5.1.10.11.4.

B. On July 22, 2025, at 3:50pm while in the company of the DFS, FSOM, and SFSM it could not be determined by direct observation that medical gas piping systems were bonded together and to the building's grounding electrode system in accordance with NFPA 70-2011, 250.104(B).

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 July 22, 2025, while in the company of the DFS, FSOM, and SFSM it was observed that multiple electrical receptacles are not provided with GFCI protection in accordance with NFPA 70-2011, 210.8(B).

Locations include:

A. 2 receptacles observed in room 5271 at 11:55am

B. Nurses' station 4329 at 12:20pm

Based on observation the facility is not storing medical gas cylinders in a compliant manner. Failure to properly store medical gas cylinders could result in an increased hazard in a fire event. This deficient practice could affect patients, staff, and visitors.

The finding is:

On July 22, 2025, while accompanied by DFS, FSOM, and SFSM medical gas cylinders were observed stored not in compliance with NFPA 99-2012, Section 11.3.2.

Locations include:

A. (5) Type "E" medical gas cylinders were observed in 5112. The room was observed unlocked.

B. More than 2 Type "E" medical gas cylinders were observed in 2269. The room was observed unlocked.

C. (6) Type "E" medical gas cylinders were observed in 1688. The room was observed unlocked.

D. (6) Type "E" medical gas cylinders were observed in 1526. The room was observed unlocked.