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A) The provider has documented information that identifies the construction type of the 2002 and 2008 additions to the building as Type I (332) construction (as defined by NFPA 220). However, the 1960 through 1978 portions of the facility are identified as Type II (000) construction (unprotected non-combustible). Most of the Type II construction is not protected by a sprinkler system. The portions of this one story facility identified as Type II (000) construction do not comply with 19.1.6.2.

The provider indicated that they are repairing the above condition as they find it. The extent of this condition is not pervasive but is not known by the provider. The surveyor confirmed that random portions of the building have unprotected steel columns and beams that support the roof, above the ceilings.

Examples; include but are not limited to: middle of the Dining Room and the Administrative Secretary's Office (above a wall pilaster).

A) Based upon random observation, the surveyor finds that exit access corridors and spaces open to exit access corridors do not comply with 19.3.6.1:

1) There is an exit access corridor in the west side of the building with the west stair and an elevator. This corridor/elevator foyer is used as a storage/holding space for construction materials, boxed supplies and equipment and one full soiled linen cart.

a) The uses in this space conflict with the
requirements of 19.3.2.1 and 19.3.6.1.

b) The exit access corridor extends to the
west and discharges outside near the
loading dock. This portion corridor was
lined with empty linen or trash carts (one
was full of trash). The use of the
corridor does not comply with 19.3.2.1
and/or 19.3.6.1 and the corridor width
was obstructed.

2) The Old Main Lobby/waiting area in the Southwest corner of the building (Smoke Compartment 1) is open to the exit access corridor and an exit path to the outside is directed through this lobby. The lobby/waiting area has smoke detection but it is not sprinklered in accordance with exception # 1 of 19.3.6.1.

a) Alternately, the space lacks constant
supervision in accordance with 19.3.6.1.
The surveyor further observes that the
single camera in this space monitors a
small portion of the space (the entrance
doors) and that the camera is monitored
in the switchboard area by a single
person with too many duties and
multiple images that are too small to
provide constant supervision of a space
via remote camera.

3) The Northwest Main Entrance to the hospital has a waiting area and reception area that is open to a corridor. The reception area is not supervised (constantly attended 24/7) and it otherwise lacks smoke detection in the reception area in accordance with exception # 1 of 19.3.6.1.

A) Based upon random testing, the surveyors find that all doors with auto-open functions (whether from push plates, sensors or coded access) are not automatically disabled upon activation of the fire alarm and sprinkler system:

1) This condition is deficient and does not comply with 7.2.1.8 at locations where the automatic opening door failed to release upon activation of the fire alarm system and the door is a designated smoke door. Example: auto-open door between Ambulatory Surgery and the Main Lobby.

2) This condition is deficient at all doors or pairs of doors with auto-opening functions where the doors are corridor doors, doors at the boundaries of suits and/or the doors are designated smoke doors (see item 1 above). Said auto-opening doors do not comply with 19.3.6.2 because the auto-opening functions are not immediately disabled and the door latching functions do not operate (doors become latched) upon activation of the fire alarm system.

3) Basement Level: The Old Materails Management Storage Room is a hazardous area. The door to the room has a magnetic hold open device but lacks smoke detectors within five feet of teh door on both sides of teh door in accordance with 7.2.1.8.

A) From random observation the surveyor finds that smoke barriers are not installed and maintained in accordance with 19.3.7.3:

1) The smoke barrier between Smoke Compartment 2 and 3 (at the east side of the building, at a pair of smoke doors near the medical/surgical unit nurse's station) is deficient. The designated smoke barrier, above the pair of doors is drywalled on one side only, above the ceiling (and is not constructed to provide a minimum of 1/2 fire rating).

A) There is a designated pair of smoke doors near the Stress Lab. These doors have vision panels that are tempered glazing instead of fire rated glazing. Check all smoke doors for the same condition.

A) The surveyor finds that hazardous areas are not enclosed in accordance with 18.3.2.1/19.3.2.1:

1) The surveyor finds that the Materials Management area in the west side of Smoke Compartment 6 is a large storage space that is relatively new construction (that must comply with 18.3.2.1).

a) Although a one hour enclosure is provided for much of the room, the pair of doors to this room lack any evidence that the doors carry a 3/4 hour fire rating.

b) The pair of doors to the room have vision panels that are not wire glass or fire rated glazing (tempered glass is installed).

c) A one hour fire rated wall to the deck above is not provided above the pair of doors (the wall construction stops just above the ceiling).

A) Obstetrics Unit: Two of two delayed egress devices on the exit doors to outside (north and south end of the corridor) do not automatically release in accordance 7.2.1.6.1 (a).

A) Portions of the Hospital and the Mobile MRI Unit have battery operated emergency lighting. Based upon random observation, the surveyors find that the battery operated emergency lights are not tested and maintained in accordance with 7.9.3 of NFPA 101.

1) The provider has no evidence of any testing or maintenance of the battery operated lighting in the Mobile MRI Unit.

2) The battery operated emergency lights in Operating Room # 4 do not work.

3) The provider lacks documentation that indicates every battery operated emergency light is tested annually for 1 1/2 hours.

A) An exit path is directed from the imaging department into the imaging waiting room. The imaging waiting room has multiple doors but lacks an illuminated exit sign identifying the door that leads to the corridor.

A) Based upon review of fire drill documentation for four quarters of 2009/2010, the surveyor finds that fire drills do not always comply with 19.7.1.2.

1) The surveyor observed that fire drills for the 1st Shift were conducted around 2:00PM without much variation. The surveyor finds that fire drills for the 1st Shift, during the four quarters reviewed were not conducted at varying times.

2) The Mobile MRI Unit is used for both outpatient and inpatient treatment. Fire drills are not conducted for this unit.

A) Based upon random observation the surveyor finds that the fire alarm system is not installed, tested and maintained in accordance with NFPA 72:

1) Strobes are not always synchronized in accordance with NFPA 72.

a) Two fire alarm strobes at the north end of the Obstetrics Unit skip (and do not flash) every fourth beat (every fourth flash, two devices do not flash when the others flash).

b) The fire alarm strobes in the corridor looking south (near Dietary) loose synchronization.

B) The facility has a Mobile MRI Unit that is used for inpatient treatment. The provider indicates that the fire alarm system within this Mobile Unit is tied directly to the Hospital's fire alarm system. The surveyors found no evidence that the fire alarm system, the fire alarm components and/or the tie in to the Hospital is tested, serviced and maintained in accordance with NFPA 72.

Based on random observation and document review during the survey walk-through, not all portions of the facilities fire alarm system is installed and maintained in accordance with NFPA 72 1999.

Findings include:

A. During the document review, the surveyors found that records were not available for the sensitivity testing of smoke detectors every other year in accordance with 7-3.2.

B. During the survey walk-through the fire alarm control panel was observed with a label identifying the circuit serving it was the emergency branch and not the life safety branch in accordance with NFPA 99 1999 3-4.2.2.2 (b) 3 a.

C. During the walk-through the breaker serving the fire alarm control panel was observed without a mechanical lock in the on position accordance with 1-5.2.5.2.

D. During the walk-through smoke detectors were observed within 3' of diffusers and not in accordance with 2-3.5.1. Locations include:

1. Receiving area in Material Management.

2. Waiting area at the south east corner of the facility.

3. In the Med/Surg corridor.

A) From random observation, the surveyors find that the sprinkler system is not installed and maintained in accordance with NFPA 13:

1) The CT Scan Equipment Room is sprinklered. A missing ceiling tile in this room compromises that sprinklered protection.

2) The Radiology Room bathroom is not sprinklered in an otherwise fully sprinklered compartment.



26665


During the survey walk-through, not all portions of the facilities sprinkler system are installed in accordance with NFPA 13 1999.

Findings include:

A. The Maternity Department IT closet was observed without a sprinkler head installed and not in accordance with NFPA 101 2000 19.3.5.1.

B. The inspectors test connections for the 2 zones were observed with a piping arrangement that appeared to have a pressure bypass and not a 1" pipe reduced down to represent the smallest orfice installed in accordance with 5-15.4.2.

Based on random observation and document review, not all portions of the facilities sprinkler system are installed in accordance with NFPA 13 1999

Findings include:

A. During the document review process it was discovered that the sprinkler system has a sprinkler control valve for the Clinic area with the handle removed and no supervisory circuit to alarm if the valve is closed and thus not in accordance with 9-7.2.1

Based on document review during the survey process, not all portions of the facilities sprinkler system are tested and maintained in accordance with NFPA 25 1998.

Findings include:

A. Documents show semi-annual testing of flow switches not quarterly in accordance with Table 9.1

B. No documents to show quarterly testing of low air alarm on dry pipe system in accordance with Table 9.1..

C. No documentation to show 3 year full flow test on the dry pipe system in accordance with Table 9.1.

A) The facility has a Mobile MRI Unit that is used for inpatient treatment. This unit had two portable fire extinguishers that are not visually inspected (and documented) monthly. One of the fire extinguishers was last inspected and serviced annually in 2009 while the other was last serviced in 2004. The fire extinguishers in the MRI are not inspected and maintained in accordance with NFPA 10.

Based on random observation during the survey walk-through, not all the facilities heating, ventilation and air conditioning system are installed in accordance with NFPA 90A 1999.

Findings include:

A. During the walk-through of the first floor corridor in Radiology a large duct extending up from the lower level was observed without fire dampers installed where it exited the shaft and not in accordance with 3-4.1.

Based on random observations during the survey walk-through, not all portions of the facilities commercial cooking equipment is installed in accordance with NFPA 96 1998.


Findings include:

A. During the walk-through of the Dietary Department 2 class K fire extinguishers were observed without signs describing their use only after the hood suppression system had discharged and not in accordance with 3-4.1.

A) The surveyor observed portable electric heaters on the window sills of Medical Record and within the office area and in the Reception Area west of the Main Entrance Lobby. The provider lacked manufacturer's documentation that indicates that the heating element of the portable heaters used do not exceed 212 degrees F, in accordance with 19.7.8.

The facility has multiple medical gas alarm panels in the older parts of the building that are not functional. These alarm panels are not covered or otherwise labeled as "not in use".

A) There is a designated smoke barrier and a pair of smoke doors near the Stress Lab. One side of the smoke barrier is sprinklered while the compartment on the other side is not. A large duct penetrates the smoke barrier above the pair of smoke doors. A smoke damper in accordance with 8.3.6 was not found.

A) The surveyor observed two eye wash stations and one emergency shower within the lab unit. One eye wash station was observed with only a cold water supply to it. The surveyor finds the facility failed to provide eye wash stations in the Laboratory in compliance with the above NFPA 99, 10-6 and ANSI Z358-1. The eye wash stations observed did not have a means for pressure and temperature control.

Based on random observation and document review during the survey walk-through, not all portions of the facilities emergency electrical system are tested and maintained in accordance with NFPA 110 and 99 1999.

Findings include:

A. During the document review process it was discovered the load bank testing had been done in 2008 and 2010, but records were not available for testing in 2009 in accordance with 110 6-4.2.2.

B. During the document review records show the generator test conducted on 4/24/10 that transfer switches 1 and 2 had not been tested that month and not in accordance with NFPA 110 6-4.5.

C. During the document review record were not available for monthly Line Isolation Monitor Testing in accordance with NFPA 99 3-3.3.4.2 (b).

Based on random observation during the survey walk-through, not all emergency electrical panels and transfer switches are readily identifiable as to which branch of the emergency electrical system they serve in accordance with NFPA 99 3-4.2.2.2.

A) From random observation, the surveyors find that electrical installations are not installed and maintained in accordance with NFPA 70:

1) Access to electrical switchgear or electrical panels is blocked by items stored in front of the switchgear at random locations throughout the storage. 3'-0" of clear space is not provided and maintained.

Examples include but are not limited to: Room 119, Dialysis Equipment Room opposite Rm 139, Maintenance Room with file cabinets in front of switchgear, Old Boiler Room

2) The facility has several electrical disconnects or switchgear that has been abandoned in place. Typically, access to this equipment is blocked by storage, the abandoned or not functioning equipment has not be removed and/or equipment is not labeled as "not in use". (Example: basement electrical room)

3) The provider has three ICU Rooms with emergency electrical outlets. These emergency outlets lack panel and circuit identification.

A) The provider has documented information that identifies the construction type of the 2002 and 2008 additions to the building as Type I (332) construction (as defined by NFPA 220). However, the 1960 through 1978 portions of the facility are identified as Type II (000) construction (unprotected non-combustible). Most of the Type II construction is not protected by a sprinkler system. The portions of this one story facility identified as Type II (000) construction do not comply with 19.1.6.2.

The provider indicated that they are repairing the above condition as they find it. The extent of this condition is not pervasive but is not known by the provider. The surveyor confirmed that random portions of the building have unprotected steel columns and beams that support the roof, above the ceilings.

Examples; include but are not limited to: middle of the Dining Room and the Administrative Secretary's Office (above a wall pilaster).

A) Based upon random observation, the surveyor finds that exit access corridors and spaces open to exit access corridors do not comply with 19.3.6.1:

1) There is an exit access corridor in the west side of the building with the west stair and an elevator. This corridor/elevator foyer is used as a storage/holding space for construction materials, boxed supplies and equipment and one full soiled linen cart.

a) The uses in this space conflict with the
requirements of 19.3.2.1 and 19.3.6.1.

b) The exit access corridor extends to the
west and discharges outside near the
loading dock. This portion corridor was
lined with empty linen or trash carts (one
was full of trash). The use of the
corridor does not comply with 19.3.2.1
and/or 19.3.6.1 and the corridor width
was obstructed.

2) The Old Main Lobby/waiting area in the Southwest corner of the building (Smoke Compartment 1) is open to the exit access corridor and an exit path to the outside is directed through this lobby. The lobby/waiting area has smoke detection but it is not sprinklered in accordance with exception # 1 of 19.3.6.1.

a) Alternately, the space lacks constant
supervision in accordance with 19.3.6.1.
The surveyor further observes that the
single camera in this space monitors a
small portion of the space (the entrance
doors) and that the camera is monitored
in the switchboard area by a single
person with too many duties and
multiple images that are too small to
provide constant supervision of a space
via remote camera.

3) The Northwest Main Entrance to the hospital has a waiting area and reception area that is open to a corridor. The reception area is not supervised (constantly attended 24/7) and it otherwise lacks smoke detection in the reception area in accordance with exception # 1 of 19.3.6.1.

A) Based upon random testing, the surveyors find that all doors with auto-open functions (whether from push plates, sensors or coded access) are not automatically disabled upon activation of the fire alarm and sprinkler system:

1) This condition is deficient and does not comply with 7.2.1.8 at locations where the automatic opening door failed to release upon activation of the fire alarm system and the door is a designated smoke door. Example: auto-open door between Ambulatory Surgery and the Main Lobby.

2) This condition is deficient at all doors or pairs of doors with auto-opening functions where the doors are corridor doors, doors at the boundaries of suits and/or the doors are designated smoke doors (see item 1 above). Said auto-opening doors do not comply with 19.3.6.2 because the auto-opening functions are not immediately disabled and the door latching functions do not operate (doors become latched) upon activation of the fire alarm system.

3) Basement Level: The Old Materails Management Storage Room is a hazardous area. The door to the room has a magnetic hold open device but lacks smoke detectors within five feet of teh door on both sides of teh door in accordance with 7.2.1.8.

A) From random observation the surveyor finds that smoke barriers are not installed and maintained in accordance with 19.3.7.3:

1) The smoke barrier between Smoke Compartment 2 and 3 (at the east side of the building, at a pair of smoke doors near the medical/surgical unit nurse's station) is deficient. The designated smoke barrier, above the pair of doors is drywalled on one side only, above the ceiling (and is not constructed to provide a minimum of 1/2 fire rating).

A) There is a designated pair of smoke doors near the Stress Lab. These doors have vision panels that are tempered glazing instead of fire rated glazing. Check all smoke doors for the same condition.

A) The surveyor finds that hazardous areas are not enclosed in accordance with 18.3.2.1/19.3.2.1:

1) The surveyor finds that the Materials Management area in the west side of Smoke Compartment 6 is a large storage space that is relatively new construction (that must comply with 18.3.2.1).

a) Although a one hour enclosure is provided for much of the room, the pair of doors to this room lack any evidence that the doors carry a 3/4 hour fire rating.

b) The pair of doors to the room have vision panels that are not wire glass or fire rated glazing (tempered glass is installed).

c) A one hour fire rated wall to the deck above is not provided above the pair of doors (the wall construction stops just above the ceiling).

A) Obstetrics Unit: Two of two delayed egress devices on the exit doors to outside (north and south end of the corridor) do not automatically release in accordance 7.2.1.6.1 (a).

A) Portions of the Hospital and the Mobile MRI Unit have battery operated emergency lighting. Based upon random observation, the surveyors find that the battery operated emergency lights are not tested and maintained in accordance with 7.9.3 of NFPA 101.

1) The provider has no evidence of any testing or maintenance of the battery operated lighting in the Mobile MRI Unit.

2) The battery operated emergency lights in Operating Room # 4 do not work.

3) The provider lacks documentation that indicates every battery operated emergency light is tested annually for 1 1/2 hours.

A) An exit path is directed from the imaging department into the imaging waiting room. The imaging waiting room has multiple doors but lacks an illuminated exit sign identifying the door that leads to the corridor.

A) Based upon review of fire drill documentation for four quarters of 2009/2010, the surveyor finds that fire drills do not always comply with 19.7.1.2.

1) The surveyor observed that fire drills for the 1st Shift were conducted around 2:00PM without much variation. The surveyor finds that fire drills for the 1st Shift, during the four quarters reviewed were not conducted at varying times.

2) The Mobile MRI Unit is used for both outpatient and inpatient treatment. Fire drills are not conducted for this unit.

A) Based upon random observation the surveyor finds that the fire alarm system is not installed, tested and maintained in accordance with NFPA 72:

1) Strobes are not always synchronized in accordance with NFPA 72.

a) Two fire alarm strobes at the north end of the Obstetrics Unit skip (and do not flash) every fourth beat (every fourth flash, two devices do not flash when the others flash).

b) The fire alarm strobes in the corridor looking south (near Dietary) loose synchronization.

B) The facility has a Mobile MRI Unit that is used for inpatient treatment. The provider indicates that the fire alarm system within this Mobile Unit is tied directly to the Hospital's fire alarm system. The surveyors found no evidence that the fire alarm system, the fire alarm components and/or the tie in to the Hospital is tested, serviced and maintained in accordance with NFPA 72.

Based on random observation and document review during the survey walk-through, not all portions of the facilities fire alarm system is installed and maintained in accordance with NFPA 72 1999.

Findings include:

A. During the document review, the surveyors found that records were not available for the sensitivity testing of smoke detectors every other year in accordance with 7-3.2.

B. During the survey walk-through the fire alarm control panel was observed with a label identifying the circuit serving it was the emergency branch and not the life safety branch in accordance with NFPA 99 1999 3-4.2.2.2 (b) 3 a.

C. During the walk-through the breaker serving the fire alarm control panel was observed without a mechanical lock in the on position accordance with 1-5.2.5.2.

D. During the walk-through smoke detectors were observed within 3' of diffusers and not in accordance with 2-3.5.1. Locations include:

1. Receiving area in Material Management.

2. Waiting area at the south east corner of the facility.

3. In the Med/Surg corridor.

A) From random observation, the surveyors find that the sprinkler system is not installed and maintained in accordance with NFPA 13:

1) The CT Scan Equipment Room is sprinklered. A missing ceiling tile in this room compromises that sprinklered protection.

2) The Radiology Room bathroom is not sprinklered in an otherwise fully sprinklered compartment.



26665


During the survey walk-through, not all portions of the facilities sprinkler system are installed in accordance with NFPA 13 1999.

Findings include:

A. The Maternity Department IT closet was observed without a sprinkler head installed and not in accordance with NFPA 101 2000 19.3.5.1.

B. The inspectors test connections for the 2 zones were observed with a piping arrangement that appeared to have a pressure bypass and not a 1" pipe reduced down to represent the smallest orfice installed in accordance with 5-15.4.2.

Based on random observation and document review, not all portions of the facilities sprinkler system are installed in accordance with NFPA 13 1999

Findings include:

A. During the document review process it was discovered that the sprinkler system has a sprinkler control valve for the Clinic area with the handle removed and no supervisory circuit to alarm if the valve is closed and thus not in accordance with 9-7.2.1

Based on document review during the survey process, not all portions of the facilities sprinkler system are tested and maintained in accordance with NFPA 25 1998.

Findings include:

A. Documents show semi-annual testing of flow switches not quarterly in accordance with Table 9.1

B. No documents to show quarterly testing of low air alarm on dry pipe system in accordance with Table 9.1..

C. No documentation to show 3 year full flow test on the dry pipe system in accordance with Table 9.1.

A) The facility has a Mobile MRI Unit that is used for inpatient treatment. This unit had two portable fire extinguishers that are not visually inspected (and documented) monthly. One of the fire extinguishers was last inspected and serviced annually in 2009 while the other was last serviced in 2004. The fire extinguishers in the MRI are not inspected and maintained in accordance with NFPA 10.

Based on random observation during the survey walk-through, not all the facilities heating, ventilation and air conditioning system are installed in accordance with NFPA 90A 1999.

Findings include:

A. During the walk-through of the first floor corridor in Radiology a large duct extending up from the lower level was observed without fire dampers installed where it exited the shaft and not in accordance with 3-4.1.

Based on random observations during the survey walk-through, not all portions of the facilities commercial cooking equipment is installed in accordance with NFPA 96 1998.


Findings include:

A. During the walk-through of the Dietary Department 2 class K fire extinguishers were observed without signs describing their use only after the hood suppression system had discharged and not in accordance with 3-4.1.

A) The surveyor observed portable electric heaters on the window sills of Medical Record and within the office area and in the Reception Area west of the Main Entrance Lobby. The provider lacked manufacturer's documentation that indicates that the heating element of the portable heaters used do not exceed 212 degrees F, in accordance with 19.7.8.

The facility has multiple medical gas alarm panels in the older parts of the building that are not functional. These alarm panels are not covered or otherwise labeled as "not in use".

A) There is a designated smoke barrier and a pair of smoke doors near the Stress Lab. One side of the smoke barrier is sprinklered while the compartment on the other side is not. A large duct penetrates the smoke barrier above the pair of smoke doors. A smoke damper in accordance with 8.3.6 was not found.

A) The surveyor observed two eye wash stations and one emergency shower within the lab unit. One eye wash station was observed with only a cold water supply to it. The surveyor finds the facility failed to provide eye wash stations in the Laboratory in compliance with the above NFPA 99, 10-6 and ANSI Z358-1. The eye wash stations observed did not have a means for pressure and temperature control.

Based on random observation and document review during the survey walk-through, not all portions of the facilities emergency electrical system are tested and maintained in accordance with NFPA 110 and 99 1999.

Findings include:

A. During the document review process it was discovered the load bank testing had been done in 2008 and 2010, but records were not available for testing in 2009 in accordance with 110 6-4.2.2.

B. During the document review records show the generator test conducted on 4/24/10 that transfer switches 1 and 2 had not been tested that month and not in accordance with NFPA 110 6-4.5.

C. During the document review record were not available for monthly Line Isolation Monitor Testing in accordance with NFPA 99 3-3.3.4.2 (b).

Based on random observation during the survey walk-through, not all emergency electrical panels and transfer switches are readily identifiable as to which branch of the emergency electrical system they serve in accordance with NFPA 99 3-4.2.2.2.

A) From random observation, the surveyors find that electrical installations are not installed and maintained in accordance with NFPA 70:

1) Access to electrical switchgear or electrical panels is blocked by items stored in front of the switchgear at random locations throughout the storage. 3'-0" of clear space is not provided and maintained.

Examples include but are not limited to: Room 119, Dialysis Equipment Room opposite Rm 139, Maintenance Room with file cabinets in front of switchgear, Old Boiler Room

2) The facility has several electrical disconnects or switchgear that has been abandoned in place. Typically, access to this equipment is blocked by storage, the abandoned or not functioning equipment has not be removed and/or equipment is not labeled as "not in use". (Example: basement electrical room)

3) The provider has three ICU Rooms with emergency electrical outlets. These emergency outlets lack panel and circuit identification.