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Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire in the event of a fire condition to escape from hazardous rooms into the exit access .

Findings include:

A. Corrected 4/16/13

B. At 2:40pm on 1/7/13 it was observed that the old whirlpool bath room located in the "West, A wing" was utilized as a storage room. The room was not provided with sprinkler protection and was not confirmed to be separated by 1-hour rated construction including a 3/4-hour self-closing door assembly.
UPDATE: The facility has purchased a replacement door, and are waiting on its arrival.

C. Corrected 4/16/13

Based on observation during the survey walk-through, not all exits are arranged so that exiting is readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect any patients, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building and safety.

Findings include:

A. Corrected 04/16/2013
1. Corrected 04/16/2013
2. Corrected 04/16/2013
3. Corrected 04/16/2013

B. At 2:35pm on 1/7/13 it was observed that the exit discharge path at the bottom of the exterior stair from the west exit from the "West, 'A' wing" was not complete. A stable path from the stair landing to the paved parking requires traversing a grass bank. The requirements of 7.7.1 are not met.
UPDATE 04/16/2013: Due to weather, progress has been slower than initially anticipated.

Based upon observation during the survey walk-thru, 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 adjacent areas.

Findings include:

A. At 9:35am on 1/8/13 it was observed that the half-light cross corridor doors located on the Level One floor near Room 1904 and the Dining room were not minimum 1 1/2-hour rated to provide continuity of the 2-hour barrier between the Type II (111) and Type II (222) construction types.
UPDATE 04/16/2013: The doors have been replaced with new 1 1/2 hour rated doors. However, the hardware installed on the doors contains the upper rod only. The doors lack the lower rod or fire pin to meet the requirement of NFPA 80, fire rating. Verification of the hardware rating was requested from the facility.

B. Corrected 04/16/2013

Based on observation during the survey walk-through on 1/7-8/13, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. Corrected 04/16/2013
1. Corrected 04/16/2013
2. Corrected 04/16/2013
3. Corrected 04/16/2013
4. Corrected 04/16/2013.


17659

Based on observation during the survey walk through while accompanied by the director of building operations, 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 and unimpeded access to the public way.

Findings include:

B. Exit discharge from the doctors lounge area had a single fixture and a single lamp which does not meet the requirements of NFPA 101-2000, Section 7.8.1.4, which states that the failure of any single lighting unit does not result in an illumination level of less than .2 ft-candles in any designated area.

UPDATE 04/16/2013: Not installed at the time of this survey.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible or properly located to clearly 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 identifying the path to an available exit from the building.

Findings include:

A. At 3:05pm on 1/7/13 it was observed that the corridor of the "East, 'B' wing" on the Level Two floor lacked exit signage to identify the second exit path from the corridor to comply with 18.2.5.9 and 18.2.10.
UPDATE 04/16/2013: under construction at the time of this survey.

B. Corrected 04/16/2013

C. At 9:50am on 1/8/13 it was observed that the directional exit sign located south of the cross corridor doors outside the Boiler room identified a path to the exterior door on the other side of the cross corridor doors. The directional signage is inappropriate on this side of the door and no signage at the exterior door is provided. The corridor leading to the materials management storage room/loading dock exterior door is not marked with exit signage and otherwise exceeds the dead end limitations of 19.2.5.10.
UPDATE 4/16/13: At the landing (corner) of the ramp an exit sign with double chevrons is recommended. At the top of the ramp the exit sign to the loading dock is not visable. Relocate the exit sign to clearly identify the 2nd exit path to the loading dock.

By direct observation the morning of 1/8/13 while in the company of the facility's Construction Project Manager the surveyor finds the ambulance entrance glass vestibule is not provided with fire sprinkler protection. The Emergency Department is considered to be fully protected by a fire protection system.

UPDATE 04/16/2013: A contractor has been contacted to make these corrections, work is pending.

Based on observations 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.

Based on observation during the survey walk-through while accompanied by the project manager and the director of building operations, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA 99-1999 and NFPA 70-1999, 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:

A. Some of the critical panels were serving items other than those allowed on the critical power system. Critical panel CB2 had circuits feeding a fire alarm panel, med gas alarm panel, (these items should be served from the life safety panel), and critical distribution panel NECB was labeled with circuits feeding life safety panels. This does not meet the requirements of NFPA 70-1999, Section 517-32 and 33.

B. Life safety panel LSB in the patient wing serves room receptacles and other non-life safety loads, (should be served by the critical branch). Life safety panels ALSB-1 and E2 are serving nurse call, lab receptacles and other non-life safety loads, and the life safety distribution panel NELSB has two circuits labeled as serving two critical panels which does not meet the requirements of NFPA 70-1999, Section 517-30 through 35.

C. Equipment panel AEMEQ serves the beam smoke detector and the PA system that should be served by the life safety system, and the fire alarm panel in the IT room in the generator building is served from the equipment panel rather than the life safety panel. This does not meet the requirements of NFPA 70-1999, Section 517-32.


UPDATE 04/16/2013: Panels have been installed and wires have been relocated to proper boxes. Item was not removed since some panels have not been energized, directories were not updated, etc. This will be reviewed at next follow-up.
On level 2, corridor niche by nursing station a new electrical panel was installed. The niche also contains two crash carts and 4 portable O2 tanks. Clearances are not being provided for the electrical panel box (NFPA 70, 1999, 110-26), and O2 tanks (NFPA 99, 1999, 8-3.1.11).