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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 18.3.6.3.

Findings include:

A. The corridor door at the southeast Janitor room on the 3rd floor did not close to a latched condition without considerable force being applied. Failure of this door to latch could expose patients, staff and visitors on the 3rd floor to the effects of fire and smoke in the event of a fire occurrance in the Janitor room.

Based on random observation during the survey walk-through, vertical openings between floors are not confirmed to be protected to comply with 18.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:

A. Miscellaneous pipe and conduit penetrations were not confirmed to be sealed in accordance with fire/smoke rated tested design assemblies. Locations observed include but are not necessarily limited to the following:

1. Numerous PVC piping penetrations through the floor of the Penthouse were observed without labeling as to the tested design used to maintain the fire rating of the floor. Piping ranged in size from 2" to 4".

2. The 1st floor Electrical room adjacent the south side elevator doors was observed with numerous conduits and sleeves which appeared to be unsealed as air movement appeared to be evident through at least one of these penetrations.

3. The 1st floor Cafeteria was observed to have an 8"+/- underfloor PVC pipe duct used between the soda supply room and the soda dispensing machine at the serving line. The piping was not readily located to observe at the basement level to confirm how these penetrations were protected.

Based on random observation during the survey walk-throughand review of the available Life Safety Plans, smoke barriers are not provided in accordance with 18.3.7.1. These deficiencies could affect all patients on the 1st floor of the facility, as well as any staff and visitors present, because the lack of access to an adjacent smoke compartment for protection from the effects of fire and smoke can compromise the health and wellfare of the occupants.

Findings include:

A. The 1st floor level is comprised of the Kitchen/Cafeteria, a PT suite, an Administration office area, a stand-by ER, and a Pharmacy. The 1st floor requires a smoke barrier to divide the floor into at least two smoke compartments to comply with 18.3.7.1. The smoke barrier was defined by staff to be the 2-hour fire barrier forming the corridor wall enclosing the Administrative office area (noted as Business occupancy). The Administrative office area 3877 sf smoke compartment has no exits available without movement through the 2-hour fire/smoke barrier corridor wall and therefore not in compliance with 18.2.4.3 because exiting would require movement into the adjacent smoke compartment which could be the compartment of fire origin.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 18.3.2.1 or 38.3.2.1 and 8.4.1. These deficiencies could affect all persons within the 1st floor Administrative area of the facility including staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the means of egress.

Findings include:

A. The Administrative office area Staff Break room contains a storage closet which is not equipped with a self-closing door to comply with 38.3.2.1, 8.4.1.2 and 8.2.4.3.5.

B. The Administrative office area file room which is deemed a normally unoccupied storage room for combustible storage was not equipped with a self-closing door to comply with 38.3.2.1, 8.4.1.2 and 8.2.4.3.5.

C. The Administrative office area reception/general office area contained closets used for general storage which did not have self-closing pairs of doors to comply with 38.3.2.1, 8.4.1.2 and 8.2.4.3.5.

Based on random observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 18.2.1 and Chapter 7. This deficiency could affect any patients using the area, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. The corridor door of the 2nd floor Dialysis room was observed to be provided with a dead bolt lock in addition to the latchset. The dead bolt lock constitutes a second releasing operation to operate the the door in noncompliance with 7.2.1.5.4.

Based on random observation during the survey walk-through, not all exit discharge locations are provided with illumination to comply with 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:

1. Exit discharge from the northwest stairwell and from the dining room/kitchen had a single light fixture which does not meet the requirements of NFPA-101, Section 7.8.1.4.

2. Exit discharge from all exits use HID type light fixtures that require a warmup period before the lights operate which does not meet the requirements of NFPA-101, Section 7.9.1.2, for lighting to be of instantaneous operation so as not to leave the exit path in darkness.

Based on document review, fire drill documentation is not completed in accordance with 18.7.1.2. This deficiency could affect all 50 patient beds in the facility as well as any staff and visitors present, because the failure to document acceptable response to the facility's fire plan may result in deficient response actions which remain unrecognized and uncorrected.

Findings include:

A. Based on document review, fire drills documentation response checklists:

1. Are not always filled out completely or consistantly by the different observers. Times are not determinable when 24-hr or AM/PM is not indicated. Location of observer is undeterminable when all locations (within, adjacent, above, or below compartment of origin) are checked on the same response sheet.

2. Do not provide documentation of the resolution of deficient responses by staff or do not otherwise document training of staff in the proper response. The 3/18/11, 6/25/11 and 11/17/11 documentation indicated that staff response was deficient regarding the closing of doors and leaving equipment in hallway.

Based on random observation during the survey walk-through, not all portions of the facility's fire alarm system are installed in accordance with NFPA 72 1999.

Findings include:

A. During the building tour smoke detectors were observed to be less than 3' from air diffusers and not in accordance with 2-3.5.1. Location observed include;

1. First floor main entry vestibule.

2. First floor in the corridor by the procedure room.

3. Second floor in the corridor by the multi-purpose room.

The three locations listed above could cause injury to patients and staff due to delayed detection of smoke.

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999), NFPA-20(1999), and NFPA-70(1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

1. The fire pump room does not have a battery operated emergency light as required by NFPA 20-2-7.4.

Based on direct observation, staff interview and document review, the portable fire extinguishers are not maintained in accordance with 9.7.4.1, 18.3.5.6 and NFPA 10. Failure to maintain accurate maintenance records for the extinguishers could result in unexpected failure of the devices when needed. The following conditions were observed:

1. Portable extinguishers throughout the building were not inspected during December 2011. The written list kept indicated that they had been inspected. However, documentation on the tags attached to the fire extinguishers was not completed. Observed locations include:

a. Two spare extinguishers in Plant Ops.

b. Three of three extinguishers in the Basement corridors.

c. FX-03-03 located at the southeast area of the 3rd floor.

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

Findings include:

A. During the walk-through of the basement equipment room Air Handling Units (AHU'S) were observed without supply air duct smoke detectors. During an interview held at that location with a maintenance staff member it was not determined the units were over 2, 000 CFM. During an interview with the Director of Operations in the Administrative Conference Room documents were provided to show all 3 unit observed were over 2,000 CFM, thus not in accordance with 4-4.2 (1). Units observed were:

1. AHU # 1.

2. AHU # 2.

3. AHU # 3.

B. Without supply smoke detection AHU shut down of the supply fan could not be verified to be in compliance with 4-4.3.

Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. The medical gas valves located on the 2nd floor identified the valves as serving room 2056. No signage for the rooms identified the 2056 reference, but it was believed the reference was for the Respiratory Therapy Department room. Failure to acurately identify the valve purpose could result in interruption of medical gas services to needed locations.

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.


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B. During the survey walk-through eye wash stations were installed without pressure/temperature regulating valves and floor receptor in accordance with NFPA 99 1999 and ANSI Z358-1-1998. Areas observed were:

1. Second Floor hand washing sink at the Nurse Station.

2. Dietary Department.

Based on random observation during the survey walk-through, not all portions of the facility's electrical distribution system are in accordance with NFPA 70 1999.

Findings include:

A. Open junction boxes were observed above the ceiling north of the west smoke barrier door on the 3rd floor in non-compliance with NFPA 70-1999, 370-25. Improper enclosure could create a shock hazard for all occupants of the building.

B. Numerous normal power electrical panels contained circuits identified as "MED GAS" with a reference to room numbers. It could not be determined what was being connected to these outlets to have them identified as serving the medical gas system. Panel directory labeling did not appear to comply with NFPA 70-1999, 384-13. Improper identification of circuits could result in disconnection of electrical services to needed locations.



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C. Staff was not able to locate were the med gas piping was bonded as required by NFPA-70, Section 250.104(c). Improper grounding could create a shock hazard for all occupants of the building.

Based on random observation during the survey walk through, portions of the elevator control system are not installed in accordance with ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

1. The surveyor could not identify a single disconnect for each elevator's emergency lighting, receptacle, and ventilation, or proper signage identifying the source feeding these disconnects as required by NFPA-70, Section 620-53.

2. NFPA-99, Section 3-4.2.2.2(b)6 requires elevator cab lighting disconnects to be served from the Life Safety branch of the emergency power system. Panel CR-1, a critical panel, had a circuit breaker marked as elevator cab lighting.

Based on random observation during the survey walk-through and staff interview, not all portions of the facility's elevator operation is in accordance with ANSI 17.1 1994.

Findings include:

A. During fire alarm testing Fire service was initiated by smoking the detector in first floor lobby and the elevator traveled to basement where staff could not place the elevator into normal operation by moving the phase 1 switch to the bypass position in accordance with 211.3 b.

B. During the document review process records were not available for the monthly operational testing in accordance with Rule 1206.7.