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A. Corrected 01/29/13.


17659


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

1. Corrected 01/29/13.
2. Corrected 01/29/13.

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


26665


A. Corrected 01/29/13.

Based on random observationduring the survey walk-through the generator equipment does not meet all requirements of NFPA-110.

Findings include:

1. The generators were located in the same room as the 12470 Volt primary power service equipment which does not comply with NFPA-110, Section 5-2.1. This deficiencies could affect all building occupants because a failure of the generators could also effect the normal power service.

2. Corrected 01/29/13.

3. Corrected 01/29/13.

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:

A. 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 by the loss of a single transfer switch.


Findings include:

1. Life Safety, Critical and Equipments branches of power were not separated throughout the building. The E-wing of the building had no separation at all, all branches were served by a single transfer switch. Areas of the building where modernization projects had been performed had some separation , but there were still emergency panels throughout that had mixtures of critical and equipment such as panel LPEMA4 and EMB4 which served patient rooms but also served room heating and cooling equipment, and panels such as LPEM4, EMB3, LPEMA3, EC3, ELS, LPEMA2, and 2CLR2 which were serving critical and life safety loads. The loads served by the emergency power system should be separated into three branches to comply with NFPA-70, Sections 517-32 through 34, and NFPA-99, Section 3-4.2.2.2 and 3-4.2.2.3.

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