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Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. 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:

On December 21, 2015 at 1:05 PM, while accompanied by the Maintenance Supervisor and a Maintenance Technician, the surveyor observed the door to Second Floor Operating Room B, now utilized as a storage room, does not carry a minimum fire resistance rating of 3/4 hour as required by 19.3.2.1. and 8.2.3.2.3.1.(2).

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

Findings include:

On December 21, 2015, while accompanied by the Maintenance Supervisor and a Maintenance Technician, the surveyor observed medical gas zone (shut-off) valves that are located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d). Locations observed include:


A. 1:00 PM: Second Floor Operating Room A.

B. 1:05 PM: Second Floor Operating Room C.

Based on observation during the survey walk-through, and staff interview, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system as required. These deficiencies could affect any patients, staff, or visitors in the building because the Essential Electrical System (EES) could become compromised.

Findings include:

A. On December 21, 2015, while accompanied by the Maintenance Supervisor and a Maintenance Technician, the surveyor observed that the facility's Type 1 EES is not 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. Electrical Panels at which this condition was observed include, but are not limited to:
1. 12:30 PM: Panel EX1, located in the 3rd Floor Center Equipment Room.

2. 1:44 PM: Panel LPE-20, located in the 2nd Floor West Corridor.
3. 8:54 AM: Panel X1, located in the 1st Floor Electrical Room.
4. 8:55 AM: Panel X, also located in the 1st Floor Electrical Room.
5. 8:35 AM: Panel HER, located in the 1st Floor ED Electrical Room.

6. 8:34 AM: also located in the 1st Floor ED Electrical Room.

7. 8:41 AM: Panel XP5, located in the 1st Floor Boiler Room.

8. 8:42 AM: Panel XP6, also located in the 1st Floor Boiler Room.

B. On December 21, 2015 at 11:10 AM, the Maintenance Supervisor stated that the facility's Type 1 EES lacks a separate transfer switch for each branch of the system (Life Safety, Critical, and Equipment) as required by NFPA 99 1999 3-4.2.2.1. and NFPA 70 1999 517-30(b)(4).

Based on observation during the survey walk-through, not all portions of the building electrical system are installed as required. 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 electrical system may fail to operate as required.

Findings include:

A. On December 21, 2015 at 11:34 AM, during an interview conducted in Second Floor Patient Sleeping Room 236, the Maintenance Supervisor confirmed that not all patient headwall locations in Patient Sleeping Rooms are provided with at least 1 circuit from the Critical Branch of the building's Type 1 Essential Electrical System (EES) as required by NFPA 70 1999 517-18(a). Locations observed include all Second Floor Patient Sleeping Room headwall locations except the west beds in the 4-Bed Patient Sleeping Room immediately east of the Nurses' Station.

B. On December 21, 2015, while accompanied by the Maintenance Supervisor and a Maintenance Technician the surveyor observed critical care patient bed locations which lack normal power outlets required by NFPA 70- 1999 517-19(a). Locations observed include:

1. 1:25 PM: Second Flr. Operating Room A.

2. 1:25 PM: Second Flr. Operating Room B.

3. 1:30 PM: Second Floor Stage I Recovery (2 Bays).

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. 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:

On December 21, 2015 at 1:05 PM, while accompanied by the Maintenance Supervisor and a Maintenance Technician, the surveyor observed the door to Second Floor Operating Room B, now utilized as a storage room, does not carry a minimum fire resistance rating of 3/4 hour as required by 19.3.2.1. and 8.2.3.2.3.1.(2).

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

Findings include:

On December 21, 2015, while accompanied by the Maintenance Supervisor and a Maintenance Technician, the surveyor observed medical gas zone (shut-off) valves that are located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d). Locations observed include:


A. 1:00 PM: Second Floor Operating Room A.

B. 1:05 PM: Second Floor Operating Room C.

Based on observation during the survey walk-through, and staff interview, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system as required. These deficiencies could affect any patients, staff, or visitors in the building because the Essential Electrical System (EES) could become compromised.

Findings include:

A. On December 21, 2015, while accompanied by the Maintenance Supervisor and a Maintenance Technician, the surveyor observed that the facility's Type 1 EES is not 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. Electrical Panels at which this condition was observed include, but are not limited to:
1. 12:30 PM: Panel EX1, located in the 3rd Floor Center Equipment Room.

2. 1:44 PM: Panel LPE-20, located in the 2nd Floor West Corridor.
3. 8:54 AM: Panel X1, located in the 1st Floor Electrical Room.
4. 8:55 AM: Panel X, also located in the 1st Floor Electrical Room.
5. 8:35 AM: Panel HER, located in the 1st Floor ED Electrical Room.

6. 8:34 AM: also located in the 1st Floor ED Electrical Room.

7. 8:41 AM: Panel XP5, located in the 1st Floor Boiler Room.

8. 8:42 AM: Panel XP6, also located in the 1st Floor Boiler Room.

B. On December 21, 2015 at 11:10 AM, the Maintenance Supervisor stated that the facility's Type 1 EES lacks a separate transfer switch for each branch of the system (Life Safety, Critical, and Equipment) as required by NFPA 99 1999 3-4.2.2.1. and NFPA 70 1999 517-30(b)(4).

Based on observation during the survey walk-through, not all portions of the building electrical system are installed as required. 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 electrical system may fail to operate as required.

Findings include:

A. On December 21, 2015 at 11:34 AM, during an interview conducted in Second Floor Patient Sleeping Room 236, the Maintenance Supervisor confirmed that not all patient headwall locations in Patient Sleeping Rooms are provided with at least 1 circuit from the Critical Branch of the building's Type 1 Essential Electrical System (EES) as required by NFPA 70 1999 517-18(a). Locations observed include all Second Floor Patient Sleeping Room headwall locations except the west beds in the 4-Bed Patient Sleeping Room immediately east of the Nurses' Station.

B. On December 21, 2015, while accompanied by the Maintenance Supervisor and a Maintenance Technician the surveyor observed critical care patient bed locations which lack normal power outlets required by NFPA 70- 1999 517-19(a). Locations observed include:

1. 1:25 PM: Second Flr. Operating Room A.

2. 1:25 PM: Second Flr. Operating Room B.

3. 1:30 PM: Second Floor Stage I Recovery (2 Bays).