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Based on staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2.

Findings include:

A. During an interview held on the east exterior of the building at 10:45 AM on August 10, 2011, the provider's Director of Maintenance stated that at least 5 canopies over exterior doors included wood structural systems and decking as prohibited by 19.1.6.2. and NFPA 220 1999 3-1.1. This deficiency could affect any building occupants attempting to exit the building through the exit doors below the canopies, because their combustion during a fire event could make the exit doors impassable.

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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.

Findings include:

A. At 10:14 AM on August 10, 2011, a masonite pegboard was observed in the Second Floor Physical Therapy Storage room. During an interview held at that location and time, the provider's Director of Maintenance was not able to verify that the pegboard carries a Class A or B flame spread rating as required by 19.3.3.2.(1). This deficiency could affect any patients or staff on the Second Floor of the building because a fire in the Storage Room could spread to adjacent spaces.

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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect any building occupants in the exit access corridors adjacent to the rooms listed, because smoke and fire could pass from them into the corridors.

Findings include:

A. At 10:15 AM on August 10, 2011, the Second Floor Southwest Nurses' Station, which is not manned 24 hours, was observed to be open to the adjacent Corridor, was observed to lack a smoke detector required by Exception 6. [subpart(a)] to 19.3.6.1.

B. At 11:05 AM on August 10, 2011, the First Floor Radiology Department Waiting Room, which was observed to be open to the adjacent Corridor, was observed to lack a smoke detector required by Exception 7. [subpart (b)] to 19.3.6.1.

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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. Doors in exit access corridors were observed that are not positive latching as required by 19.3.6.3.2. These deficiencies could affect any patients and staff using the First Floor Corridors of the building, because smoke and fire may not be contained within the rooms in which a fire occurs. Locations observed include (all First Floor):

1. 11:05 AM August 10, 2011: Pair of doors to Radiology Department suite.

2. 11:24 AM August 10, 2011: Pair of doors to Emergency Department suite.

.

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 efficiencies could affect any patients or staff in the building because fire may not be contained to the identified hazardous areas.

Findings include:

A. At 9:32 Am on August 10, 2011, combustible materials (mattresses) were observed being stored adjacent to the existing boilers as prohibited by 19.3.2.1.
B. At 9:40 AM on August 10, 2011, a functioning oven/stove was observed in the Second Floor Kitchenette. At the time the oven/stove was observed, combustible products were observed being stored on top of the burners.C. Doors to hazardous areas were observed that are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1(2). Locations observed include:

1. 9:51 AM August 10, 2011: Second Floor Cardiac Rehab suite, Large Storage Room.
2. 10:08 AM August 10, 2011: Supply Room served by Nurses' Station. Surveyor 14290 notes that several holes were also observed at this door which are not sealed against the passage of smoke.

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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.

Findings include:

A. At 9:26 AM on August 10, 2011, the travel distance from the most remote point of the (Third Floor level) Mechanical Penthouse (as measured to the door to the Second Floor door to the North Exit Stair because the Stair serving the Penthouse discharges interior to the building on the Second Floor) was observed to be in excess of 100 feet as prohibited by Subpart (c) of Exception 1. to 7.12.1. This deficiency could affect any staff working in the Mechanical Penthouse because the excessive travel distance could prevent that staff from reaching an exit under fire conditions.

B. Doors from the roof to the (Third Floor level) Mechanical Penthouse were observed to be capable of being locked to prevent staff from er-entering the building from the roof, as prohibited by 7.2.1.5.3. These deficiencies could affect any staff working on the roof because they could be prevented from reaching an exit under fire conditions. Locations observed include:

1. 9:31 AM August 10, 2011: South door from Mechanical Penthouse to roof.

2. 9:37 AM August 10, 2011: East door from Mechanical Penthouse to roof.

C. At 11:10 AM on August 10, 2011, an accordion door was observed, in the Corridor immediately east of the Emergency Department, which could be placed across the Corridor and secured against egress as prohibited by 7.2.1.4.1. (because the door is not a side-hinged, swinging door) and 7.2.1.5.1. (because the door can be secured against egress). This deficiency could affect any patients or staff in the Corridor because they could be prevented from reaching an exit under fire conditions.

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Based on random observation during the survey walk-through, document review, and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During an interview held in the First Floor Conference Room at 8:40 AM on August 10, 2011, the provider's Director of Maintenance was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 19.7.1.1. This deficiency could affect all patients and staff in the building because the lack of knowledge about such life safety components could result in the failure to protect the components properly. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include (but are not necessarily limited to):

1. Occupancy classifications.

2. Portions of the building covered by an automatic sprinkler system.

3. Fire barriers and their fire resistance ratings, including occupancy separations, horizontal exits, building separations, and separations between disparate construction types.

4. Shaft enclosures and their fire resistance ratings, including exit stairs, exit discharge enclosures, elevators, and ventilation shafts.

5. Smoke barrier walls and areas (in square feet) of smoke compartments.

6. Exit access corridors and designated corridor walls.

7. The limits and areas (in square feet) of all suites.

8. Hazardous areas and their fire resistance ratings.

9. Exits.

10. Other special fire protection features such as areas of the building covered by a smoke evacuation system.

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Based on staff interview, not all portions of the facility's air conditioning and ventilating systems are installed and maintained in accordance with NFPA 90A.

Findings include:

A. During the document review process, it was determined that dampers are not tested every 4 years as required by NFPA 90A 1999 3-4.7. During an interview held in the First Floor Conference Room at 1:56 PM on August 10, 2011, the provider's Director of Maintenance confirmed this observation. These deficiencies could affect any patients and staff in the building because the dampers could fail to operate properly under fire and smoke conditions. Dampers not tested periodically include:
1. Fire dampers.

2. Smoke dampers.

.


26665


Based on random observation during the survey walk-through, not all portions of the facility's heating, ventilating and air conditioning system are in accordance with NFPA 90A 1999.

Findings include:

A. During the walk-through of the penthouse at 9:30 am on August 10, 2011 a return air duct was observed penetrating the 2 hour floor without a fire damper installed in accordance with 3-3.2.

B. During the walk-through of the second floor at 9:45 am on August 10, 2011 a return air duct was observed penetrating the 2 hour floor without a fire damper installed in accordance with 3-3.2.

These deficiencies could allow fire to travel from floor to floor endangering patients and staff.

.

Based on random observation, document review and staff interview during the survey walk-through, not all portions of the facility's commercial cooking equipment are installed and maintained in accordance with NFPA 96 1998.

Findings include:

A. During the Dietary Department survey walk-through at 1:15 PM on August 10, 2011 the range exhaust hood filters appeared to have gaps in which grease laden vapors could bypass the filters, thus not in accordance with 3-2.3.

B. During the Dietary Department survey walk-through the hood was observed without collection containers (less than 1 gallon) at the end of the collection rail holding the filters.

C. During the Dietary Department survey walk-through the hood area was observed without replacement air duct to make up for the amount of air exhausted by the hood exhaust fan in accordance with 5-3.

D. During an interview held in Dietary with the Director of Maintenance at the range hood it was discovered the only time the hood was cleaned was when the Director of Dietary requested maintenance to provide cleaning and not in accordance with Table 8-3.1 for semi-annual cleaning and inspection for moderate cooking facilities.

E. The hood was observed without a tag to identify the certified cleaning and inspection company with the date of the last cleaning and inspection in accordance with 8-3.1.1.

F. The range exhaust hood appeared to be of other construction than externally welded seams in accordance with 4-5.2.1.

Any of the above deficiencies could result in a range hood fire causing injury to patients and staff.

.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. Medical gas tanks were observed being stored that are less than 20'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(1). These deficiencies could affect any patients and staff in the immediate area of the stored medical gases, because the gases could contribute to any fire which develops in the combustible materials. Locations observed include:

1. 9:45 AM August 10, 2011: Second Floor Cardiac Rehab Department, 7 tanks.

2. 1:15 PM August 10, 2011: First Floor Recovery Unit Transition Space, 3 tanks.

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Based on random observation during the survey walk-through, not all medical gas piping systems are installed and maintained in accordance with NFPA 99.

A. At 9:44 AM on August 10, 2011, the manual medical gas zone (shut-off) valves serving the medical gas outlets in the Second Floor Cardiac Rehab Department were observed to be located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d). This deficiency could affect any patients and staff in the immediate area of the medical gas outlets, because staff may be prevented from shutting off the gases under emergency conditions.

.

Based on random observation during the survey walk-through, not all duct penetrations at smoke barriers are protected against the passage of smoke in accordance with 8.3.5.

Findings include:

A. At 10:11 AM on August 10, 2011, a duct that penetrates the designated smoke barrier wall on the west side of the Second Floor (above the pair of cross-corridor doors) was observed which is not equipped with a smoke damper required by 19.3.7.3. and 8.3.5.1. This deficiency could affect any patients and staff on the Second Floor because smoke could be allowed to migrate between smoke compartments.

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Based on random observation during the survey walk-through and staff interview, the building's emergency generator is not installed and maintained in accordance with NFPA 99. The generator is located outside in an unheated building. These deficiencies could affect any patients and staff in the building because they could result in the failure of the emergency generator to operate under emergency conditions.

Findings include:

A. The emergency generator was observed to lack a remote manual stop station, located outside the room housing the generator, as required by NFPA 110 1999 3-5.5.6. During an interview held at the site of the generator at 10:48 AM on August 10, 2011, the provider's Director of Maintenance confirmed this observation.

B. The room housing the emergency generator was observed to lack a battery-powered emergency light required by NFPA 70 1999 517-32.(e), NFPA 99 1999 3-4.2.2.2.(b)(5), and NFPA 110 1999 5-3.1. During an interview held at the site of the generator at 10:47 AM on August 10, 2011, the provider's Director of Maintenance confirmed this observation.

C. The room housing the emergency generator was observed to lack a duplex electrical receptacle required by NFPA 70 1999 517-32.(e), NFPA 99 1999 3-4.2.2.2.(b)(5), and NFPA 110 1999 5-3.1. During an interview held in the First Floor Conference Room at 1:47 PM on August 10, 2011, the provider's Director of Maintenance confirmed this observation.

D. At 10:50 AM on August 10, 2011, the starter batteries for the emergency generator were observed to lack an automatically controlled heater required by NFPA 110 1999 3-3.1.

E. At 10:49 AM on August 10, 2011; the room housing the emergency generator was observed to be used for storage, as prohibited by NFPA 99 1999 3-4.1.1.6.(a). and NFPA 110 1999 5-11.1.

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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 document review and staff interview, the emergency generator is not inspected and tested in accordance with NFPA 99. These deficiencies could affect any patients and staff in the building because the emergency generator could fail to operate under emergency conditions.

Findings include:

A. During the document review process, it could not be determined that the emergency generator is tested under load for 30 minutes each month, as required by NFPA 99 1999 3-4.4.1.1. and NFPA 110 6-4.2., because the Generator Test Logs do not indicate when power is transferred back off of the generator. This determination was confirmed by the provider's Director of Maintenance during an interview held in the First Floor Conference Room at 1:40 PM on August 10, 2011.

B. During the document review process, it was determined that an annual load bank test is not performed on the emergency generator, as required by NFPA 110 1999 6-4.2.2. This determination was confirmed by the provider's Director of Maintenance during an interview held in the First Floor Conference Room at 1:42 PM on August 10, 2011.

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Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect ay patients being housed or treated in the cited locations, because electrical power may not be available for necessary equipment under all circumstances.

Findings include:

A. General care patient beds were observed at which 1 circuit is not from the building emergency electrical system as required by NFPA 70 1999 517-18(a). During an interview held in a Second Floor Patient Sleeping Room at 9:54 AM on August 10, 2011, the provider's Director of Maintenance confirmed that this condition exists at all 25 general patient care beds in the facility.

B. At 11:25 AM on August 10, 2011, the 4 First Floor Emergency Department Exam Rooms were observed lack at least 1 duplex receptacle which is served by the building emergency electrical system as required by NFPA 70 1999 517-18(a).

C. At 9:58 AM on August 10, 2011, the 4 Second Floor Intensive Care Unit beds were observed lack at least 1 duplex receptacle which is served by the building normal power electrical system as required by NFPA 70 1999 517-18(a).

.

Based on staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2.

Findings include:

A. During an interview held on the east exterior of the building at 10:45 AM on August 10, 2011, the provider's Director of Maintenance stated that at least 5 canopies over exterior doors included wood structural systems and decking as prohibited by 19.1.6.2. and NFPA 220 1999 3-1.1. This deficiency could affect any building occupants attempting to exit the building through the exit doors below the canopies, because their combustion during a fire event could make the exit doors impassable.

.

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.

Findings include:

A. At 10:14 AM on August 10, 2011, a masonite pegboard was observed in the Second Floor Physical Therapy Storage room. During an interview held at that location and time, the provider's Director of Maintenance was not able to verify that the pegboard carries a Class A or B flame spread rating as required by 19.3.3.2.(1). This deficiency could affect any patients or staff on the Second Floor of the building because a fire in the Storage Room could spread to adjacent spaces.

.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect any building occupants in the exit access corridors adjacent to the rooms listed, because smoke and fire could pass from them into the corridors.

Findings include:

A. At 10:15 AM on August 10, 2011, the Second Floor Southwest Nurses' Station, which is not manned 24 hours, was observed to be open to the adjacent Corridor, was observed to lack a smoke detector required by Exception 6. [subpart(a)] to 19.3.6.1.

B. At 11:05 AM on August 10, 2011, the First Floor Radiology Department Waiting Room, which was observed to be open to the adjacent Corridor, was observed to lack a smoke detector required by Exception 7. [subpart (b)] to 19.3.6.1.

.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. Doors in exit access corridors were observed that are not positive latching as required by 19.3.6.3.2. These deficiencies could affect any patients and staff using the First Floor Corridors of the building, because smoke and fire may not be contained within the rooms in which a fire occurs. Locations observed include (all First Floor):

1. 11:05 AM August 10, 2011: Pair of doors to Radiology Department suite.

2. 11:24 AM August 10, 2011: Pair of doors to Emergency Department suite.

.

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 efficiencies could affect any patients or staff in the building because fire may not be contained to the identified hazardous areas.

Findings include:

A. At 9:32 Am on August 10, 2011, combustible materials (mattresses) were observed being stored adjacent to the existing boilers as prohibited by 19.3.2.1.
B. At 9:40 AM on August 10, 2011, a functioning oven/stove was observed in the Second Floor Kitchenette. At the time the oven/stove was observed, combustible products were observed being stored on top of the burners.C. Doors to hazardous areas were observed that are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1(2). Locations observed include:

1. 9:51 AM August 10, 2011: Second Floor Cardiac Rehab suite, Large Storage Room.
2. 10:08 AM August 10, 2011: Supply Room served by Nurses' Station. Surveyor 14290 notes that several holes were also observed at this door which are not sealed against the passage of smoke.

.

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.

Findings include:

A. At 9:26 AM on August 10, 2011, the travel distance from the most remote point of the (Third Floor level) Mechanical Penthouse (as measured to the door to the Second Floor door to the North Exit Stair because the Stair serving the Penthouse discharges interior to the building on the Second Floor) was observed to be in excess of 100 feet as prohibited by Subpart (c) of Exception 1. to 7.12.1. This deficiency could affect any staff working in the Mechanical Penthouse because the excessive travel distance could prevent that staff from reaching an exit under fire conditions.

B. Doors from the roof to the (Third Floor level) Mechanical Penthouse were observed to be capable of being locked to prevent staff from er-entering the building from the roof, as prohibited by 7.2.1.5.3. These deficiencies could affect any staff working on the roof because they could be prevented from reaching an exit under fire conditions. Locations observed include:

1. 9:31 AM August 10, 2011: South door from Mechanical Penthouse to roof.

2. 9:37 AM August 10, 2011: East door from Mechanical Penthouse to roof.

C. At 11:10 AM on August 10, 2011, an accordion door was observed, in the Corridor immediately east of the Emergency Department, which could be placed across the Corridor and secured against egress as prohibited by 7.2.1.4.1. (because the door is not a side-hinged, swinging door) and 7.2.1.5.1. (because the door can be secured against egress). This deficiency could affect any patients or staff in the Corridor because they could be prevented from reaching an exit under fire conditions.

.

Based on random observation during the survey walk-through, document review, and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1.

Findings include:

A. During an interview held in the First Floor Conference Room at 8:40 AM on August 10, 2011, the provider's Director of Maintenance was not able to identify the locations of certain key building life safety components which comprise a portion of the facility's fire protection plan required by 19.7.1.1. This deficiency could affect all patients and staff in the building because the lack of knowledge about such life safety components could result in the failure to protect the components properly. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include (but are not necessarily limited to):

1. Occupancy classifications.

2. Portions of the building covered by an automatic sprinkler system.

3. Fire barriers and their fire resistance ratings, including occupancy separations, horizontal exits, building separations, and separations between disparate construction types.

4. Shaft enclosures and their fire resistance ratings, including exit stairs, exit discharge enclosures, elevators, and ventilation shafts.

5. Smoke barrier walls and areas (in square feet) of smoke compartments.

6. Exit access corridors and designated corridor walls.

7. The limits and areas (in square feet) of all suites.

8. Hazardous areas and their fire resistance ratings.

9. Exits.

10. Other special fire protection features such as areas of the building covered by a smoke evacuation system.

.

Based on staff interview, not all portions of the facility's air conditioning and ventilating systems are installed and maintained in accordance with NFPA 90A.

Findings include:

A. During the document review process, it was determined that dampers are not tested every 4 years as required by NFPA 90A 1999 3-4.7. During an interview held in the First Floor Conference Room at 1:56 PM on August 10, 2011, the provider's Director of Maintenance confirmed this observation. These deficiencies could affect any patients and staff in the building because the dampers could fail to operate properly under fire and smoke conditions. Dampers not tested periodically include:
1. Fire dampers.

2. Smoke dampers.

.


26665


Based on random observation during the survey walk-through, not all portions of the facility's heating, ventilating and air conditioning system are in accordance with NFPA 90A 1999.

Findings include:

A. During the walk-through of the penthouse at 9:30 am on August 10, 2011 a return air duct was observed penetrating the 2 hour floor without a fire damper installed in accordance with 3-3.2.

B. During the walk-through of the second floor at 9:45 am on August 10, 2011 a return air duct was observed penetrating the 2 hour floor without a fire damper installed in accordance with 3-3.2.

These deficiencies could allow fire to travel from floor to floor endangering patients and staff.

.

Based on random observation, document review and staff interview during the survey walk-through, not all portions of the facility's commercial cooking equipment are installed and maintained in accordance with NFPA 96 1998.

Findings include:

A. During the Dietary Department survey walk-through at 1:15 PM on August 10, 2011 the range exhaust hood filters appeared to have gaps in which grease laden vapors could bypass the filters, thus not in accordance with 3-2.3.

B. During the Dietary Department survey walk-through the hood was observed without collection containers (less than 1 gallon) at the end of the collection rail holding the filters.

C. During the Dietary Department survey walk-through the hood area was observed without replacement air duct to make up for the amount of air exhausted by the hood exhaust fan in accordance with 5-3.

D. During an interview held in Dietary with the Director of Maintenance at the range hood it was discovered the only time the hood was cleaned was when the Director of Dietary requested maintenance to provide cleaning and not in accordance with Table 8-3.1 for semi-annual cleaning and inspection for moderate cooking facilities.

E. The hood was observed without a tag to identify the certified cleaning and inspection company with the date of the last cleaning and inspection in accordance with 8-3.1.1.

F. The range exhaust hood appeared to be of other construction than externally welded seams in accordance with 4-5.2.1.

Any of the above deficiencies could result in a range hood fire causing injury to patients and staff.

.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99.

Findings include:

A. Medical gas tanks were observed being stored that are less than 20'-0" from combustibles as prohibited by NFPA 99 1999 8-3.1.11.2(c)(1). These deficiencies could affect any patients and staff in the immediate area of the stored medical gases, because the gases could contribute to any fire which develops in the combustible materials. Locations observed include:

1. 9:45 AM August 10, 2011: Second Floor Cardiac Rehab Department, 7 tanks.

2. 1:15 PM August 10, 2011: First Floor Recovery Unit Transition Space, 3 tanks.

.

Based on random observation during the survey walk-through, not all medical gas piping systems are installed and maintained in accordance with NFPA 99.

A. At 9:44 AM on August 10, 2011, the manual medical gas zone (shut-off) valves serving the medical gas outlets in the Second Floor Cardiac Rehab Department were observed to be located in the same room as the station outlets they serve, as prohibited by NFPA 99 1999 4.3.1.2.3(d). This deficiency could affect any patients and staff in the immediate area of the medical gas outlets, because staff may be prevented from shutting off the gases under emergency conditions.

.

Based on random observation during the survey walk-through, not all duct penetrations at smoke barriers are protected against the passage of smoke in accordance with 8.3.5.

Findings include:

A. At 10:11 AM on August 10, 2011, a duct that penetrates the designated smoke barrier wall on the west side of the Second Floor (above the pair of cross-corridor doors) was observed which is not equipped with a smoke damper required by 19.3.7.3. and 8.3.5.1. This deficiency could affect any patients and staff on the Second Floor because smoke could be allowed to migrate between smoke compartments.

.

Based on random observation during the survey walk-through and staff interview, the building's emergency generator is not installed and maintained in accordance with NFPA 99. The generator is located outside in an unheated building. These deficiencies could affect any patients and staff in the building because they could result in the failure of the emergency generator to operate under emergency conditions.

Findings include:

A. The emergency generator was observed to lack a remote manual stop station, located outside the room housing the generator, as required by NFPA 110 1999 3-5.5.6. During an interview held at the site of the generator at 10:48 AM on August 10, 2011, the provider's Director of Maintenance confirmed this observation.

B. The room housing the emergency generator was observed to lack a battery-powered emergency light required by NFPA 70 1999 517-32.(e), NFPA 99 1999 3-4.2.2.2.(b)(5), and NFPA 110 1999 5-3.1. During an interview held at the site of the generator at 10:47 AM on August 10, 2011, the provider's Director of Maintenance confirmed this observation.

C. The room housing the emergency generator was observed to lack a duplex electrical receptacle required by NFPA 70 1999 517-32.(e), NFPA 99 1999 3-4.2.2.2.(b)(5), and NFPA 110 1999 5-3.1. During an interview held in the First Floor Conference Room at 1:47 PM on August 10, 2011, the provider's Director of Maintenance confirmed this observation.

D. At 10:50 AM on August 10, 2011, the starter batteries for the emergency generator were observed to lack an automatically controlled heater required by NFPA 110 1999 3-3.1.

E. At 10:49 AM on August 10, 2011; the room housing the emergency generator was observed to be used for storage, as prohibited by NFPA 99 1999 3-4.1.1.6.(a). and NFPA 110 1999 5-11.1.

.

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 document review and staff interview, the emergency generator is not inspected and tested in accordance with NFPA 99. These deficiencies could affect any patients and staff in the building because the emergency generator could fail to operate under emergency conditions.

Findings include:

A. During the document review process, it could not be determined that the emergency generator is tested under load for 30 minutes each month, as required by NFPA 99 1999 3-4.4.1.1. and NFPA 110 6-4.2., because the Generator Test Logs do not indicate when power is transferred back off of the generator. This determination was confirmed by the provider's Director of Maintenance during an interview held in the First Floor Conference Room at 1:40 PM on August 10, 2011.

B. During the document review process, it was determined that an annual load bank test is not performed on the emergency generator, as required by NFPA 110 1999 6-4.2.2. This determination was confirmed by the provider's Director of Maintenance during an interview held in the First Floor Conference Room at 1:42 PM on August 10, 2011.

.

Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect ay patients being housed or treated in the cited locations, because electrical power may not be available for necessary equipment under all circumstances.

Findings include:

A. General care patient beds were observed at which 1 circuit is not from the building emergency electrical system as required by NFPA 70 1999 517-18(a). During an interview held in a Second Floor Patient Sleeping Room at 9:54 AM on August 10, 2011, the provider's Director of Maintenance confirmed that this condition exists at all 25 general patient care beds in the facility.

B. At 11:25 AM on August 10, 2011, the 4 First Floor Emergency Department Exam Rooms were observed lack at least 1 duplex receptacle which is served by the building emergency electrical system as required by NFPA 70 1999 517-18(a).

C. At 9:58 AM on August 10, 2011, the 4 Second Floor Intensive Care Unit beds were observed lack at least 1 duplex receptacle which is served by the building normal power electrical system as required by NFPA 70 1999 517-18(a).

.