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During the survey walk-through, accompanied by the EMS & Safety Director, it was observed that not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could compromise the use of the exit access corridor during a fire/smoke event.

Findings include:

A. At 2:40 PM on 9/5/2013 it was observed that the corridor door in the south east
corner of the main level Emergency Department is equipped with electric panic
hardware that did not latch when activated by the fire alarm. The bolt did not engage
the receptor in the frame when extended, thus leaving the door unlatched. 19.3.6.3.2

During the survey walk-through, accompanied by the EMS & Safety Director, it
was observed that not all doors that are a part of an exit access comply with 19.2.10.
This deficiency could affect the path of egress taken from the north wing by patients,
staff, or visitors not familiar with the hospital, by impeding movement to the exit
discharge.

Findings include:

A. At 11:33 AM on 9/5/2013 it was observed that the cross corridor doors that
separate the second floor elevator lobby from the north exit access corridor are
equipped with panic hardware and lie in the path of egress from the corridor but do not
lead to an exit. The actual path of egress is perpendicular to the corridor and
immediately adjacent to the cross corridor doors, and exit signage that serves the exit
could be interpreted as directing the path of egress into the elevator lobby. The cross
corridor doors are not marked " No Exit " . 19.2.10.1, 7.10.8.1

During the survey walk-through, accompanied by the EMS & Safety Director, it was
observed that not all designated or required smoke barrier walls are constructed
or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.
This deficiency could result in the effects of fire and smoke transferring from one side
of the smoke barrier to the other and compromising the safety of patients, staff and
visitors.

Findings include:

A. At 11:30 AM on 11/5/2013 near the second floor nurses' station alarm cables were
observed to pass through an unprotected opening in the smoke barrier wall above the
cross corridor doors. 19.3.7.3, 8.3.6.1

During the survey walk-through, accompanied by the EMS & Safety Director, it was
observed that not all designated or required smoke barrier walls are constructed
or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.
This deficiency could result in the effects of fire and smoke transferring from one side
of the smoke barrier to the other and compromising the safety of patients, staff and
visitors.

Findings include:
A. At 11:05 AM on 11/5/2013 in the north patient corridor of the first floor of the Annex
an unprotected opening was observed in the smoke barrier wall above the cross
corridor doors. 19.3.7.3

During the survey walk-through, accompanied by the EMS & Safety Director, it was observed that not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2. These deficiencies could affect all patients, staff, and visitors within the smoke compartment of the location by allowing smoke and fire to escape from hazardous rooms into the exit access corridor.

Findings include:

A. At 1:45 PM on 11/5/2013 the door located in the north east corner of the first floor
laundry room was held open by a floor magnet that is not tied to the building fire alarm
system and thus is not automatic closing. 19.3.2.1

B. At 11:23 AM on 11/5/2013 the corridor door to the second floor pharmacy storage
room had an unprotected opening of approximately ¾ inch diameter through it at the
lockset. 19.3.2.1

During the survey walk-through, accompanied by the EMS & Safety Director, it was observed that exit access is not arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the
building.

Findings include:

A. At 11:21 AM on 11/5/2013 near the second floor pre/post op testing rooms the
exterior exit discharge doors were equipped with separate thumb turn locks, which
require two operations to pass through the doors. 19.2.2.2.1, 7.2.1.5.4

B. At 2:43 PM on 11/5/2013 at the corridor south of the first floor emergency
department the cross corridor doors are equipped with panic hardware that was not
functioning properly. The push bar did not unlatch the door, which could only be
opened if the top rod was pulled manually. 19.2.2.2.1, 7.2.1.5.1

C. At 2:40 PM on 11/5/2013 it was observed that corridor door in the south east
corner of the first floor Emergency Department is equipped with an electric magnet
lock. Staff was unable to verify that the locking mechanism is permanently disabled,
therefore this application for a lockable door does not comply with 19.2.2.2.4.

During the survey walk-through, accompanied by the EMS & Safety Director, paths of egress were observed that were not identified by exit signage in accordance with 19.2.10.1 and 7.10. These deficiencies could affect all patients, staff, and visitors in the areas described by preventing those occupants from readily identifying the path of egress.

Findings include:

A. Exit signs are not provided to identify the direction of egress from corridors or
rooms to comply with 19.2.5.9, 19.2.10.1, and 7.10. Locations noted include the
following:

1. At 11:35 AM on 11/5/2013 it was noted that exit signage was not visible from the second floor elevator lobby. 19.2.1, 7.10

During the survey walk-through, accompanied by the EMS & Safety Director, paths of egress were observed that were not identified by exit signage in accordance with 19.2.10.1 and 7.10. These deficiencies could affect all patients, staff, and visitors in the areas described by preventing those occupants from readily identifying the path of egress.

Findings include:
A. At 11:15 AM on 11/5/2013 it was noted that exit signage was not visible from the
corridor adjacent to the first floor Annex conference room. 19.2.5.9, 19.2.10.1

Based on random observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the fire alarm system installation did not meet all requirements of NFPA-72. This could affect all occupants of the building if the elevators do not operate properly during an emergency.

Findings include:

A. At 11:40 AM on 11/5/2013 it was observed that the traction elevator equipment room is equipped with a sprinkler, but there is not a heat detector located within 2' of the sprinkler head as required by NFPA-72, Section 3-9.4, and there is no means to automatically disconnect the main power supply to the elevator prior to application of water in the machine room or shaft as required by ASME 17.1, Section 102.2.c.3.

Based on random observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the fire alarm system installation did not meet all of the requirements of NFPA-72. This could affect all occupants of the building if the fire alarm system does not operate during a fire emergency.

Findings include:
A. At 11:00 AM on 11/5/2013 it was observed that the fire alarm panel was located in an unmanned location, the basement equipment room near the board room, and the room is not equipped with a smoke detector as required by NFPA-72, Section 1-5.6.

B. At 11:15 AM on 11/5/2013 it was observed that the hydraulic elevator equipment room is equipped with sprinklers, but there is not a heat detector located within 2' of each sprinkler head as required by ASME 17.1, Section 102.2.c.3, and NFPA-72, Section 3-9.4.

By direct observation, while in the company of the Maintenance Supervisor the afternoon of 11/5/13, the surveyor finds fire protection sprinklers are obstructed from providing complete coverage at the following locations. This deficiency could affect all building occupants in the event of fire in these areas. (NFPA 13, 1999, 5-5.5.1)

Findings include:

A. First floor dietary main kitchen:
At 2:10 PM on 11/5/2013 it was observed that the ventilation bulkhead along the east wall at the ceiling and by the portion of the exhaust hood on the west wall not protected by the Ansul fire protection system.

B. Clean linen room across from the first floor laundry entrance:
At 2:35 PM on 11/5/2013 it was observed that the soffit along the south wall obstructs sprinkler coverage.

Based on random observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the generator installation did not meet all of the requirements of NFPA-110. This could affect all occupants of the building if the generator does not operate properly during a power outage.

Findings include:

A. At 11:50 AM on 11/5/2013 it was observed that the generator at the south end of the building is not equipped with a battery heater as required by NFPA-110, Section 3-3.1.

A. Due to the number, variety, and severity of the life safety deficiencies observed
during the survey walk-through, the provider shall institute the 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.

Based on random observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the hospital if the emergency power system does not operate correctly.

Findings include:

A. At 1:25 on 11/5/2013 it was observed that the transfer switch in the electrical room on the second floor at the north end of the building next to the elevator is serving all three branches of emergency power. This does not meet the requirements of NFPA-70, Section 517-30 through 517-35, for a system that serves over 150 KVA in loads.

B. At 1:30 PM on 11/5/2013 it was observed that panel 2EC in the second floor north electrical room is serving a mix of life safety, critical and equipment loads which does not meet the requirements of NFPA-70, Section 517-32 through 517-34.

C. At 2:05 PM on 11/5/2013 it was observed that the transfer switches and panels serving the emergency power in the mechanical room north of the laundry are not properly separated into branches to meet the requirements of NFPA70, Sections 517-30 through 517-35.

D. At 2:20 PM on 11/5/2013 it was observed that the transfer switch serving the kitchen and boiler room is serving mostly equipment but has some loads that are required to be served from the life safety panel, including some exit and emergency lighting served from panel HE, and the elevator cab lighting served from panel LEA, which does not meet the requirements of NFPA-70, Section 517-32.

Based on random observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70.

Findings include:

A. At 1:45 PM on 11/5/2013 it was observed that the cab lighting for the traction elevator is not served from the life safety panel as required by NFPA-70, Section 517-32, and there is not a disconnect switch for cab lighting and controls within the elevator equipment room as required by NFPA-70, Section 620-22. This could affect any occupant of the building using the elevator during a power outage.

During the survey walk-through, accompanied by the EMS & Safety Director, it was observed that not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could compromise the use of the exit access corridor during a fire/smoke event.

Findings include:

A. At 2:40 PM on 9/5/2013 it was observed that the corridor door in the south east
corner of the main level Emergency Department is equipped with electric panic
hardware that did not latch when activated by the fire alarm. The bolt did not engage
the receptor in the frame when extended, thus leaving the door unlatched. 19.3.6.3.2

During the survey walk-through, accompanied by the EMS & Safety Director, it
was observed that not all doors that are a part of an exit access comply with 19.2.10.
This deficiency could affect the path of egress taken from the north wing by patients,
staff, or visitors not familiar with the hospital, by impeding movement to the exit
discharge.

Findings include:

A. At 11:33 AM on 9/5/2013 it was observed that the cross corridor doors that
separate the second floor elevator lobby from the north exit access corridor are
equipped with panic hardware and lie in the path of egress from the corridor but do not
lead to an exit. The actual path of egress is perpendicular to the corridor and
immediately adjacent to the cross corridor doors, and exit signage that serves the exit
could be interpreted as directing the path of egress into the elevator lobby. The cross
corridor doors are not marked " No Exit " . 19.2.10.1, 7.10.8.1

During the survey walk-through, accompanied by the EMS & Safety Director, it was
observed that not all designated or required smoke barrier walls are constructed
or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.
This deficiency could result in the effects of fire and smoke transferring from one side
of the smoke barrier to the other and compromising the safety of patients, staff and
visitors.

Findings include:

A. At 11:30 AM on 11/5/2013 near the second floor nurses' station alarm cables were
observed to pass through an unprotected opening in the smoke barrier wall above the
cross corridor doors. 19.3.7.3, 8.3.6.1

During the survey walk-through, accompanied by the EMS & Safety Director, it was
observed that not all designated or required smoke barrier walls are constructed
or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.
This deficiency could result in the effects of fire and smoke transferring from one side
of the smoke barrier to the other and compromising the safety of patients, staff and
visitors.

Findings include:
A. At 11:05 AM on 11/5/2013 in the north patient corridor of the first floor of the Annex
an unprotected opening was observed in the smoke barrier wall above the cross
corridor doors. 19.3.7.3

During the survey walk-through, accompanied by the EMS & Safety Director, it was observed that not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2. These deficiencies could affect all patients, staff, and visitors within the smoke compartment of the location by allowing smoke and fire to escape from hazardous rooms into the exit access corridor.

Findings include:

A. At 1:45 PM on 11/5/2013 the door located in the north east corner of the first floor
laundry room was held open by a floor magnet that is not tied to the building fire alarm
system and thus is not automatic closing. 19.3.2.1

B. At 11:23 AM on 11/5/2013 the corridor door to the second floor pharmacy storage
room had an unprotected opening of approximately ¾ inch diameter through it at the
lockset. 19.3.2.1

During the survey walk-through, accompanied by the EMS & Safety Director, it was observed that exit access is not arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the
building.

Findings include:

A. At 11:21 AM on 11/5/2013 near the second floor pre/post op testing rooms the
exterior exit discharge doors were equipped with separate thumb turn locks, which
require two operations to pass through the doors. 19.2.2.2.1, 7.2.1.5.4

B. At 2:43 PM on 11/5/2013 at the corridor south of the first floor emergency
department the cross corridor doors are equipped with panic hardware that was not
functioning properly. The push bar did not unlatch the door, which could only be
opened if the top rod was pulled manually. 19.2.2.2.1, 7.2.1.5.1

C. At 2:40 PM on 11/5/2013 it was observed that corridor door in the south east
corner of the first floor Emergency Department is equipped with an electric magnet
lock. Staff was unable to verify that the locking mechanism is permanently disabled,
therefore this application for a lockable door does not comply with 19.2.2.2.4.

During the survey walk-through, accompanied by the EMS & Safety Director, paths of egress were observed that were not identified by exit signage in accordance with 19.2.10.1 and 7.10. These deficiencies could affect all patients, staff, and visitors in the areas described by preventing those occupants from readily identifying the path of egress.

Findings include:

A. Exit signs are not provided to identify the direction of egress from corridors or
rooms to comply with 19.2.5.9, 19.2.10.1, and 7.10. Locations noted include the
following:

1. At 11:35 AM on 11/5/2013 it was noted that exit signage was not visible from the second floor elevator lobby. 19.2.1, 7.10

During the survey walk-through, accompanied by the EMS & Safety Director, paths of egress were observed that were not identified by exit signage in accordance with 19.2.10.1 and 7.10. These deficiencies could affect all patients, staff, and visitors in the areas described by preventing those occupants from readily identifying the path of egress.

Findings include:
A. At 11:15 AM on 11/5/2013 it was noted that exit signage was not visible from the
corridor adjacent to the first floor Annex conference room. 19.2.5.9, 19.2.10.1

Based on random observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the fire alarm system installation did not meet all requirements of NFPA-72. This could affect all occupants of the building if the elevators do not operate properly during an emergency.

Findings include:

A. At 11:40 AM on 11/5/2013 it was observed that the traction elevator equipment room is equipped with a sprinkler, but there is not a heat detector located within 2' of the sprinkler head as required by NFPA-72, Section 3-9.4, and there is no means to automatically disconnect the main power supply to the elevator prior to application of water in the machine room or shaft as required by ASME 17.1, Section 102.2.c.3.

Based on random observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the fire alarm system installation did not meet all of the requirements of NFPA-72. This could affect all occupants of the building if the fire alarm system does not operate during a fire emergency.

Findings include:
A. At 11:00 AM on 11/5/2013 it was observed that the fire alarm panel was located in an unmanned location, the basement equipment room near the board room, and the room is not equipped with a smoke detector as required by NFPA-72, Section 1-5.6.

B. At 11:15 AM on 11/5/2013 it was observed that the hydraulic elevator equipment room is equipped with sprinklers, but there is not a heat detector located within 2' of each sprinkler head as required by ASME 17.1, Section 102.2.c.3, and NFPA-72, Section 3-9.4.

By direct observation, while in the company of the Maintenance Supervisor the afternoon of 11/5/13, the surveyor finds fire protection sprinklers are obstructed from providing complete coverage at the following locations. This deficiency could affect all building occupants in the event of fire in these areas. (NFPA 13, 1999, 5-5.5.1)

Findings include:

A. First floor dietary main kitchen:
At 2:10 PM on 11/5/2013 it was observed that the ventilation bulkhead along the east wall at the ceiling and by the portion of the exhaust hood on the west wall not protected by the Ansul fire protection system.

B. Clean linen room across from the first floor laundry entrance:
At 2:35 PM on 11/5/2013 it was observed that the soffit along the south wall obstructs sprinkler coverage.

Based on random observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the generator installation did not meet all of the requirements of NFPA-110. This could affect all occupants of the building if the generator does not operate properly during a power outage.

Findings include:

A. At 11:50 AM on 11/5/2013 it was observed that the generator at the south end of the building is not equipped with a battery heater as required by NFPA-110, Section 3-3.1.

A. Due to the number, variety, and severity of the life safety deficiencies observed
during the survey walk-through, the provider shall institute the 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.

Based on random observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the hospital if the emergency power system does not operate correctly.

Findings include:

A. At 1:25 on 11/5/2013 it was observed that the transfer switch in the electrical room on the second floor at the north end of the building next to the elevator is serving all three branches of emergency power. This does not meet the requirements of NFPA-70, Section 517-30 through 517-35, for a system that serves over 150 KVA in loads.

B. At 1:30 PM on 11/5/2013 it was observed that panel 2EC in the second floor north electrical room is serving a mix of life safety, critical and equipment loads which does not meet the requirements of NFPA-70, Section 517-32 through 517-34.

C. At 2:05 PM on 11/5/2013 it was observed that the transfer switches and panels serving the emergency power in the mechanical room north of the laundry are not properly separated into branches to meet the requirements of NFPA70, Sections 517-30 through 517-35.

D. At 2:20 PM on 11/5/2013 it was observed that the transfer switch serving the kitchen and boiler room is serving mostly equipment but has some loads that are required to be served from the life safety panel, including some exit and emergency lighting served from panel HE, and the elevator cab lighting served from panel LEA, which does not meet the requirements of NFPA-70, Section 517-32.

Based on random observation during the survey walk through while accompanied by the facility electrician, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70.

Findings include:

A. At 1:45 PM on 11/5/2013 it was observed that the cab lighting for the traction elevator is not served from the life safety panel as required by NFPA-70, Section 517-32, and there is not a disconnect switch for cab lighting and controls within the elevator equipment room as required by NFPA-70, Section 620-22. This could affect any occupant of the building using the elevator during a power outage.