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Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

Findings include:

A. At 1:28 PM on April 17, 2013, the roof structure for the First Floor MRI Trailer Entry was observed to be of wood construction, as prohibited by 19.1.6.2.

B. At 9:39 AM on April 17, 2013, an unprotected steel column was observed in the Ground Floor Contaminated Linen Room.

Based on random observation during the survey walk-through and staff interview, not all wall and ceiling finishes in rooms or spaces could be verified as carrying a flame spread rating of Class A or B or less in accordance with 19.3.3.1. This deficiency could affect any patients, staff, or visitors in the area of the cited room by permitting smoke to develop in an occupied portion of the building.

Findings include:

A. At 1:12 PM on April 17, 2013, "Masonite" pegboard, which does not constitute a Class C finish, was observed in the (1977 Building) Orthopedic Supply Room.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to enter the egress corridor.

Findings include:

A. During a test of the building fire alarm system conducted at 11:05 AM on April 18, 2013, the pair of doors, located in a corridor wall at the west end of the First Floor (2001 Addition) Emergency Department, were observed to not be positive latching as required by 19.3.6.3.2.

B. During a test of the building fire alarm system conducted at 11:01 AM on April 18, 2013, the rolling shutter at the First Floor (1977 Building) Patient Accounts Office was observed to not close as required by 19.3.6.3.2.

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

A. Pipe or other penetrations were observed in smoke barrier walls that are not sealed against the passage of smoke as required by 19.3.7.3. and 8.3.6.1. Locations observed include:

1. 10:43 AM April 17, 2013: Smoke barrier adjacent to (1977 Building) Patient Sleeping Room 349.

2. 1:06 PM April 17, 2013: Smoke barrier adjacent to (1977 Building) Patient Sleeping Room 249.

Based on random 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. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. At 1:36 PM on April 17, 2013, the door to the First Floor (1977 Building) Laboratory Storage Room was observed to not be self-closing as required by 19.3.2.1. and 8.2.3.2.3.1(1).

B. During a test of the building fire alarm system conducted at 11:09 AM on April 18, 2013, the hold-open feature of the automatic door operator at the Ground Floor (2001 Addition) Loading Dock was observed to not release to close as required by 19.3.2.1. and 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, not all designated exit passageways are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. At 9:47 AM on April 17, 2013, the doors from the normally unoccupied rooms listed below were observed to open into the designated (First Floor) Exit Passageway for Exit Stair 5, as prohibited by 7.1.3.2.1(d):

1. The Garage.

2. A Paint Storage Room.
3. The Maintenance Shop.

4. A Mechanical Room.

B. At 9:53 AM on April 17, 2013, an Elevator was observed which opens directly into the designated (First Floor) Exit Passageway for Exit Stair 4, as prohibited by 9.4.7.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 9:48 AM on April 17, 2013, the exterior side of the exterior door, which serves the designated Exit Passageway for Exit Stair 5, was observed to not be level with the floor on the interior side for at least the width of the door leaf as required by 7.2.1.3.

B. On April 17, 2013, a series of walk-in coolers or freezers were observed, in the First Floor Kitchen, which can be secured by padlock against egress as prohibited by 7.2.1.5.1. Locations observed include:
1. 10:02 AM: 3 walk-in coolers or freezers in the Kitchen.

2. 10:03 AM: 2 exterior walk-in coolers or freezers adjacent to the First Floor Kitchen.

C. On April 17, 2013, the following deficiencies were observed in the Ground Floor (1977 Building) Pharmacy:

1. The door to the corridor was observed to be equipped with a locking mechanism which requires special knowledge to operate (a push button release) as prohibited by 7.2.1.5.4.

2. No path of egress from the suite was identified because no exit sign, complying with 7.10., is provided.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 38.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 8:05 AM on April 18, 2013, a series of doors in the Second Floor egress path were observed to be capable of being secured against passage, thus creating a condition which does not comply with 38.2.4.2. because both required exits could not be reached from any point of the building story. Doors which can be secured against passage include:

1. Door 233A.
2. Door to Therapy Room D218.

Based on random observation during the survey walk-through, not all designated or required fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

A. On April 17, 2013, a series of unsealed pipe or other penetrations were observed in 2 hour rated fire barriers as prohibited by 8.2.4.2.4.2. Locations observed include:

1. 8:53 AM: Above the Third Floor cross-corridor doors between the 1977 Building and the Buildings to the west.

2. 9:05 AM: Above the Second Floor cross-corridor doors between the 1977 Building and the Buildings to the west.

3. 10:16 AM: Above the First Floor cross-corridor doors between the 1977 Building and the Buildings to the west.

B. During a test of the building fire alarm system conducted at 11:10 AM on April 18, 2013, a pair of doors in the 2 hour fire barrier at the (2001 Addition) Ground Floor, directly north of the Visitor Elevator Lobby, were observed to not be positive latching as required by 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, (staff interview, and document review,) exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

A. At 9:04 AM on April 17, 2013, the sign at exit stairs were observed that read "STAIR" and not "EXIT" as required by 7.10.1.3.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 38.2.10.1. and 7.10. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

A. At 8:10 AM on April 18, 2013, no exit signs were observed which direct building occupants toward the Northeast Exit Stair as required by 7.10.

Based on document review and staff interview, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. These deficiencies could affect any patients, staff, or visitors in the building because staff may not be properly prepared for a fire emergency, or because the connection of the fire alarm system to an outside agency may not be functioning properly.

Findings include:

A. Based on document review conducted at 2:35 PM on April 17, 2013, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2012 and 2013, fire drills for Shift C were conducted at the similar times listed:

1. March 30, 2012: 6:30 AM.

2. April 18, 2012: 6:10 AM.

3. August 26, 2012: 5:45 AM.

4. December 14, 2013: 5:47 AM.

5. March 27, 2012: 6:08 AM.

B. During an interview held in the Second Floor Administrative Conference Room at 2:40 PM on April 17, 2013, the provider's Director of Facilities Management confirmed that fire drills do not include the transmission of a fire alarm signal as required by 19.7.1.2.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

A. On April 17, 2013, rooms provided with standard pendant sprinkler heads were observed at which ceiling tile were observed to be missing or at which openings in the drywall ceiling were observed, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1. Locations observed include (both First Floor 1977 Building):

1. 10:22 AM: Vestibule for Exit Stair 3.

2. 1:24 PM: CT Mechanical Room.

B. On April 18, 2013, Materials were observed being stored less than 18" below standard pendant sprinkler heads as prohibited by NFPA 13 1999 5-6.6. Locations observed include (both Ground Floor 1977 Building):

1. 10:01 AM: Central Sterile Storage Room.

2. 10:02 AM: Central Supply Storage Room.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

A. Carts, furnishings, and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. 10:34 AM April 17, 2013: Vending machine in Third Floor (1977 Building) Corridor.

2. 9:44 AM April 18, 2013: Several wheelchairs in First Floor (2001 Addition) east Lobby area across from Reception Desk.

Based on random observation during the survey walk-through, not all medical gas piping systems are installed and maintained in accordance with NFPA 99. These deficiencies could affect any patients in the cited area because the medical gas system could become compromised.

A. At 1:51 PM on April 17, 2013, the medical gas area alarm panel serving the Ground Floor of the 1977 Building was observed to be located in the Biomedical Engineering Office (which can be secured against entry), and not in an accessible location as required by by NFPA 99 1999 4-3.1.2.2(c)(2).

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.

Based on random observation during the survey walk-through and document review, the facility's Type 1 Emergency Electrical System (EES) is not divided into the Life Safety Branch, the Critical Branch, and the Equipment Branch as required by NFPA 99 and NFPA 70. These deficiencies could affect any patients, staff, or visitors in the building because the EES could become compromised.

Findings include:

A. The facility's Type 1 EES was observed to not be divided into a Life Safety, Critical, and Equipment Branch as required by NFPA 99 1999 3-4.2.2.2. and NFPA 70 1999 517-30. All Electrical Panels listed below were observed to serve electrical loads which are required to be served by different branches of the EES. Based on a review of the facilities Electrical Panel Circuit Directories conducted at 9:03 AM on April 18, 2013, Electrical Panels at which this condition exists include, but are not limited to:

1. 1977 Building:
a. Third Floor Electrical Panel 3C, at which Circuit 8 is identified as serving the Nurse Call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], Circuit 12 is identified as serving the Fire Alarm System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(a) and NFPA 70 1999 517-32(c)(1)], and other circuits are identified as serving other normal electrical loads.
b. Second Floor Electrical Panel 2C, at which Circuit 8 is identified as serving the Nurse Call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], and other circuits are identified as serving other normal electrical loads.

c. First Floor Electrical Panel 1C, at which Circuit 32 is identified as serving the Nurse Call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], Circuit 34 is identified as serving the Fire Alarm System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(a) and NFPA 70 1999 517-32(c)(1)], and other circuits are identified as serving other normal electrical loads.

d. Electrical Panel EL, at which Circuit 5 is identified as serving Nurse Exit Lights [required to be served by the Life Safety Branch per NFPA 99 1999 3-4.2.2.2(b)(2) and NFPA 70 1999 517-32(b)], Circuits 4 and 7 are identified as serving Emergency Lights [required to be served by the Life Safety Branch per NFPA 99 1999 3-4.2.2.2(b)(1) and NFPA 70 1999 517-32(a)], Circuit 6 is shown as serving a Medical Gas Alarm Panel [required to be served by the Life Safety Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(b) and NFPA 70 1999 517-32(c)(2)] and other circuits are identified as serving other normal electrical loads.

e. Ground Floor Electrical Panel 1-EM, identified as being an Emergency Panel, was identified as serving normal electrical loads including:

1) Corridor receptacles (Circuits 1 and 2).

2) Normal Kitchen lighting (Circuits 6, 7, 9, 10, 11, and 12.

2. 2001 Addition/2011 Vertical Expansion:

a. At 9:03 AM on April 18, 2013, Fourth Floor Electrical Panel LS2A, identified as a Life Safety Panel, which was observed to serve the Nurse call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], and the Infant Abduction System [which is not permitted to be served by the Life Safety Branch by NFPA 99 1999 3-4.2.2.2(b) and NFPA 70 1999 517-32].

b. At 9:55 Am on April 18, 2013, First Floor Electrical Panel ES1A was observed to serve the Fire Alarm System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(a) and NFPA 70 1999 517-32(c)(1)], and other circuits identified as serving other normal electrical loads.

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any patients being treated in the cited areas because emergency power may not be available under certain conditions, or may affect any patients, staff, or visitors in the building because the building's electrical system could become compromised.

Findings include:

A. At 9:53 AM on April 18, 2013, Circuit 5 of 2001 Addition First Floor Electrical Panel LS1 was identified as a "Bad Buss" and no breaker was present within the Electrical Panel.

Based on random observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

Findings include:

A. At 1:28 PM on April 17, 2013, the roof structure for the First Floor MRI Trailer Entry was observed to be of wood construction, as prohibited by 19.1.6.2.

B. At 9:39 AM on April 17, 2013, an unprotected steel column was observed in the Ground Floor Contaminated Linen Room.

Based on random observation during the survey walk-through and staff interview, not all wall and ceiling finishes in rooms or spaces could be verified as carrying a flame spread rating of Class A or B or less in accordance with 19.3.3.1. This deficiency could affect any patients, staff, or visitors in the area of the cited room by permitting smoke to develop in an occupied portion of the building.

Findings include:

A. At 1:12 PM on April 17, 2013, "Masonite" pegboard, which does not constitute a Class C finish, was observed in the (1977 Building) Orthopedic Supply Room.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to enter the egress corridor.

Findings include:

A. During a test of the building fire alarm system conducted at 11:05 AM on April 18, 2013, the pair of doors, located in a corridor wall at the west end of the First Floor (2001 Addition) Emergency Department, were observed to not be positive latching as required by 19.3.6.3.2.

B. During a test of the building fire alarm system conducted at 11:01 AM on April 18, 2013, the rolling shutter at the First Floor (1977 Building) Patient Accounts Office was observed to not close as required by 19.3.6.3.2.

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

A. Pipe or other penetrations were observed in smoke barrier walls that are not sealed against the passage of smoke as required by 19.3.7.3. and 8.3.6.1. Locations observed include:

1. 10:43 AM April 17, 2013: Smoke barrier adjacent to (1977 Building) Patient Sleeping Room 349.

2. 1:06 PM April 17, 2013: Smoke barrier adjacent to (1977 Building) Patient Sleeping Room 249.

Based on random 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. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. At 1:36 PM on April 17, 2013, the door to the First Floor (1977 Building) Laboratory Storage Room was observed to not be self-closing as required by 19.3.2.1. and 8.2.3.2.3.1(1).

B. During a test of the building fire alarm system conducted at 11:09 AM on April 18, 2013, the hold-open feature of the automatic door operator at the Ground Floor (2001 Addition) Loading Dock was observed to not release to close as required by 19.3.2.1. and 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, not all designated exit passageways are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. At 9:47 AM on April 17, 2013, the doors from the normally unoccupied rooms listed below were observed to open into the designated (First Floor) Exit Passageway for Exit Stair 5, as prohibited by 7.1.3.2.1(d):

1. The Garage.

2. A Paint Storage Room.
3. The Maintenance Shop.

4. A Mechanical Room.

B. At 9:53 AM on April 17, 2013, an Elevator was observed which opens directly into the designated (First Floor) Exit Passageway for Exit Stair 4, as prohibited by 9.4.7.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 9:48 AM on April 17, 2013, the exterior side of the exterior door, which serves the designated Exit Passageway for Exit Stair 5, was observed to not be level with the floor on the interior side for at least the width of the door leaf as required by 7.2.1.3.

B. On April 17, 2013, a series of walk-in coolers or freezers were observed, in the First Floor Kitchen, which can be secured by padlock against egress as prohibited by 7.2.1.5.1. Locations observed include:
1. 10:02 AM: 3 walk-in coolers or freezers in the Kitchen.

2. 10:03 AM: 2 exterior walk-in coolers or freezers adjacent to the First Floor Kitchen.

C. On April 17, 2013, the following deficiencies were observed in the Ground Floor (1977 Building) Pharmacy:

1. The door to the corridor was observed to be equipped with a locking mechanism which requires special knowledge to operate (a push button release) as prohibited by 7.2.1.5.4.

2. No path of egress from the suite was identified because no exit sign, complying with 7.10., is provided.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 38.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. At 8:05 AM on April 18, 2013, a series of doors in the Second Floor egress path were observed to be capable of being secured against passage, thus creating a condition which does not comply with 38.2.4.2. because both required exits could not be reached from any point of the building story. Doors which can be secured against passage include:

1. Door 233A.
2. Door to Therapy Room D218.

Based on random observation during the survey walk-through, not all designated or required fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

A. On April 17, 2013, a series of unsealed pipe or other penetrations were observed in 2 hour rated fire barriers as prohibited by 8.2.4.2.4.2. Locations observed include:

1. 8:53 AM: Above the Third Floor cross-corridor doors between the 1977 Building and the Buildings to the west.

2. 9:05 AM: Above the Second Floor cross-corridor doors between the 1977 Building and the Buildings to the west.

3. 10:16 AM: Above the First Floor cross-corridor doors between the 1977 Building and the Buildings to the west.

B. During a test of the building fire alarm system conducted at 11:10 AM on April 18, 2013, a pair of doors in the 2 hour fire barrier at the (2001 Addition) Ground Floor, directly north of the Visitor Elevator Lobby, were observed to not be positive latching as required by 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, (staff interview, and document review,) exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

A. At 9:04 AM on April 17, 2013, the sign at exit stairs were observed that read "STAIR" and not "EXIT" as required by 7.10.1.3.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 38.2.10.1. and 7.10. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

A. At 8:10 AM on April 18, 2013, no exit signs were observed which direct building occupants toward the Northeast Exit Stair as required by 7.10.

Based on document review and staff interview, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. These deficiencies could affect any patients, staff, or visitors in the building because staff may not be properly prepared for a fire emergency, or because the connection of the fire alarm system to an outside agency may not be functioning properly.

Findings include:

A. Based on document review conducted at 2:35 PM on April 17, 2013, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2012 and 2013, fire drills for Shift C were conducted at the similar times listed:

1. March 30, 2012: 6:30 AM.

2. April 18, 2012: 6:10 AM.

3. August 26, 2012: 5:45 AM.

4. December 14, 2013: 5:47 AM.

5. March 27, 2012: 6:08 AM.

B. During an interview held in the Second Floor Administrative Conference Room at 2:40 PM on April 17, 2013, the provider's Director of Facilities Management confirmed that fire drills do not include the transmission of a fire alarm signal as required by 19.7.1.2.

Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

A. On April 17, 2013, rooms provided with standard pendant sprinkler heads were observed at which ceiling tile were observed to be missing or at which openings in the drywall ceiling were observed, which compromises sprinkler coverage as prohibited by NFPA 13 1999 5-6.4.1.1. Locations observed include (both First Floor 1977 Building):

1. 10:22 AM: Vestibule for Exit Stair 3.

2. 1:24 PM: CT Mechanical Room.

B. On April 18, 2013, Materials were observed being stored less than 18" below standard pendant sprinkler heads as prohibited by NFPA 13 1999 5-6.6. Locations observed include (both Ground Floor 1977 Building):

1. 10:01 AM: Central Sterile Storage Room.

2. 10:02 AM: Central Supply Storage Room.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

A. Carts, furnishings, and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. 10:34 AM April 17, 2013: Vending machine in Third Floor (1977 Building) Corridor.

2. 9:44 AM April 18, 2013: Several wheelchairs in First Floor (2001 Addition) east Lobby area across from Reception Desk.

Based on random observation during the survey walk-through, not all medical gas piping systems are installed and maintained in accordance with NFPA 99. These deficiencies could affect any patients in the cited area because the medical gas system could become compromised.

A. At 1:51 PM on April 17, 2013, the medical gas area alarm panel serving the Ground Floor of the 1977 Building was observed to be located in the Biomedical Engineering Office (which can be secured against entry), and not in an accessible location as required by by NFPA 99 1999 4-3.1.2.2(c)(2).

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.

Based on random observation during the survey walk-through and document review, the facility's Type 1 Emergency Electrical System (EES) is not divided into the Life Safety Branch, the Critical Branch, and the Equipment Branch as required by NFPA 99 and NFPA 70. These deficiencies could affect any patients, staff, or visitors in the building because the EES could become compromised.

Findings include:

A. The facility's Type 1 EES was observed to not be divided into a Life Safety, Critical, and Equipment Branch as required by NFPA 99 1999 3-4.2.2.2. and NFPA 70 1999 517-30. All Electrical Panels listed below were observed to serve electrical loads which are required to be served by different branches of the EES. Based on a review of the facilities Electrical Panel Circuit Directories conducted at 9:03 AM on April 18, 2013, Electrical Panels at which this condition exists include, but are not limited to:

1. 1977 Building:
a. Third Floor Electrical Panel 3C, at which Circuit 8 is identified as serving the Nurse Call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], Circuit 12 is identified as serving the Fire Alarm System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(a) and NFPA 70 1999 517-32(c)(1)], and other circuits are identified as serving other normal electrical loads.
b. Second Floor Electrical Panel 2C, at which Circuit 8 is identified as serving the Nurse Call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], and other circuits are identified as serving other normal electrical loads.

c. First Floor Electrical Panel 1C, at which Circuit 32 is identified as serving the Nurse Call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], Circuit 34 is identified as serving the Fire Alarm System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(a) and NFPA 70 1999 517-32(c)(1)], and other circuits are identified as serving other normal electrical loads.

d. Electrical Panel EL, at which Circuit 5 is identified as serving Nurse Exit Lights [required to be served by the Life Safety Branch per NFPA 99 1999 3-4.2.2.2(b)(2) and NFPA 70 1999 517-32(b)], Circuits 4 and 7 are identified as serving Emergency Lights [required to be served by the Life Safety Branch per NFPA 99 1999 3-4.2.2.2(b)(1) and NFPA 70 1999 517-32(a)], Circuit 6 is shown as serving a Medical Gas Alarm Panel [required to be served by the Life Safety Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(b) and NFPA 70 1999 517-32(c)(2)] and other circuits are identified as serving other normal electrical loads.

e. Ground Floor Electrical Panel 1-EM, identified as being an Emergency Panel, was identified as serving normal electrical loads including:

1) Corridor receptacles (Circuits 1 and 2).

2) Normal Kitchen lighting (Circuits 6, 7, 9, 10, 11, and 12.

2. 2001 Addition/2011 Vertical Expansion:

a. At 9:03 AM on April 18, 2013, Fourth Floor Electrical Panel LS2A, identified as a Life Safety Panel, which was observed to serve the Nurse call System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(c)(5) and NFPA 70 1999 517-33(a)(5)], and the Infant Abduction System [which is not permitted to be served by the Life Safety Branch by NFPA 99 1999 3-4.2.2.2(b) and NFPA 70 1999 517-32].

b. At 9:55 Am on April 18, 2013, First Floor Electrical Panel ES1A was observed to serve the Fire Alarm System [required to be served by the Critical Branch per NFPA 99 1999 3-4.2.2.2(b)(3)(a) and NFPA 70 1999 517-32(c)(1)], and other circuits identified as serving other normal electrical loads.

Based on random observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any patients being treated in the cited areas because emergency power may not be available under certain conditions, or may affect any patients, staff, or visitors in the building because the building's electrical system could become compromised.

Findings include:

A. At 9:53 AM on April 18, 2013, Circuit 5 of 2001 Addition First Floor Electrical Panel LS1 was identified as a "Bad Buss" and no breaker was present within the Electrical Panel.