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Based on document review and based on random observation with the Director of Facilities and the Safety Officer present, the surveyor observed that portions of the East/West Building do not comply with 19.1.6.2.

Findings include:

1. The 6th Floor Admitting Office at the west end of the East/West Building was found to have a suspended lay-in ceiling below a plaster ceiling. The plaster ceiling is attached directly to the reinforced concrete structure above. A portion of the plaster ceiling was removed and a 4' strip running parallel to the two hour fire separation between East/West and Hamilton was fire-proofed for the entire width of the room. The provider had no explanation as to why this area was fire-proofed. The provider also lacks U L Design Numbers for the floor/ceiling assemblies used in the East/West Building where the plaster ceilings have been removed.

Based on document review, personnel interview and based on random observation on 04/08/14, 04/09/14 and 04/11/14, with the Director of Facilities and the Safety Officer present, the surveyor observed that this building has inpatient programs on three floors and does not comply with 19.1.6.2 for construction type requirements for healthcare. Failure to install and maintain fire rated construction could cause the building to collapse during a fire emergency.

Findings Include:

1. The 8th Floor Roof/Ceiling Assemblies appear to have three different construction assemblies, all of which include unprotected steel structure above the ceilings. The surveyor observed lay-in ceiling systems with light fixture protection and ceiling diffuser fire dampers. The provider lacked U L Design Numbers for 2 hour fire rated Floor/Ceiling Assemblies or or 1 1/2 hour Roof/Ceiling assemblies for the systems used directly above the 8th Floor.

a. Moved to K-056

2. During the initial survey interview, the Director of Facilities and the Safety Officer identified the Glen Oak Building as Type II (211), Type II (222) and as Type II (000) construction. most of the Glen Oak Building has been identified as either Type II (111) construction or Type II (000) construction, by the provider and/or by the provider's consultants. The surveyor observed that the structural system above the ceiling for Floors 2 through 7 is reinforced concrete with less than a two hour fire rating, based on the following:

a. Based on random observation on multiple floors, including floors which have been renovated, the surveyor observed no ceiling condition which could be considered to be part of a fire rated Floor/ceiling Assembly, except above the 8th Floor.

b. The provider lacks U L Design Numbers for all Floor/Ceiling Assemblies and for all Roof/Ceiling Assemblies which have been used in this building to demonstrate compliance as Type II (222) or greater construction, as defined by NFPA 220.

c. A report from Rolf Jensen and Assoc. dated June 27, 1995, identifies the building as Type II (111) construction.

d. A report from the Joint Commission dated May 12, 1995, identifies the building as Type II (000) construction.

e. This condition (K012) was cited in this building on a Medicare Survey dated 04/13/1993. The provider submitted an FSES dated June 27, 1995, as part of the corrective action for that survey. The FSES was for the 1985 Life Safety Code: This FSES is not valid as a demonstration of compliance for the 2000 Edition of NFPA 101.

Based on random observation with the Director of Facilities and the HVAC staff present on 08/11/14, the surveyor observed that patient care areas are not separated from means of egress corridors which does not comply with 19.3.6. Lack of properly separated patient care areas from means of egress corridors could result in the inability of staff to confine a fire/smoke event and effectively evacuate patients from the area.

Findings include:

1. New Deficiency-08/11/2014 at 10:30am while accompanied by the Director of Facilities, 2nd Floor Crescent Building: Recovery is not a designated suite (not shown on the Life Safety floor plans). This area contains patient care bays with privacy curtains which are open to the means of egress corridor. This condition does not comply with 19.3.6.1 exception 1(a).

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

Findings include:

A. At 1:30 PM on April 10, 2014, while accompanied by the provider's Electrician and HVAC Specialist: The Second Floor Surgical Department horizontal sliding door from the Corridor to the Staff Area serving Operating Rooms 1 through 9 (which constitutes a suite because the doors from the Staff Area Passage to the Operating Rooms are not positive latching) was observed to not be positive latching as required by 19.3.6.3.2.

A. Based on document review of plans dated 3/31/14 and based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that designated smoke compartments do not comply with 19.3.7.1. Failure to identify and maintain required smoke barriers could allow smoke to spread beyond the compartment of fire origin.

Findings include:

1. The plans dated 03/31/14 identify the entire East/West building as one single smoke compartment on the 5th, 6th, 7th and 8th Floors. Although one hour fire barriers further subdivide each floor, these one hour fire barriers are not identified as smoke barriers. A two hour barrier identified on the north end of the East Building is also not identified as a two hour fire/smoke barrier.

The travel distance on Floors 5, 6 and 7 from the north end of the East Building, as indicated on the smoke compartment plans, exceeds the 200' travel distance limitations of 19.3.7.1 to the closest identified smoke barrier doors.

New 01/08/15: The East / West Building - The 6th Floor has an Information Technologies (IT) Unit which is located on the north side of a designated one hour fire barrier in the north part of the East Building. The Life Safety Plans dated 03/31/14 identified the Unit a bussiness occupancy but lack the required two hour fire rated separation from the healthcare occupancy to comply with 19.1.2.1 of NFPA 101 2000 Edition.

Based on random observation during the survey walk-through, accompanied by two contractor foremen, the surveyor finds that not all stair shafts used as exits are constructed in accordance with 7.2. 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. The distance between guardrails in exit stair enclosures was observed to be in excess of 4" as prohibited by Subpart (3) to 7.2.2.4.6. Exit stair enclosures at which this condition was observed include:

1. 9:00 AM on April 11, 2014: North Hamilton Exit Stair.

2. 9:10 AM on April 11, 2014: West Hamilton Exit Stair.

B. Corrected 8/11/14
C. Corrected 8/11/14

A. 1.a. Corrected 01/08/2015
b. Corrected 08/11/2104
c. Corrected 08/11/2014
2. Corrected 08/11/2014


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B. Corrected 08/11/2014


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C. Based on random observation during the survey walk-through, with the Construction Manager and an HVAC Staff person present, the surveyor finds that 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:

1. Corrected 01/08/15
2. New deficiency - 01/08/15: 8th Floor Crescent Building, on the morning of 01/08/15 the exit access corridor near the Public Elevator Lobby of Crescent Building was observed to be lack an exit signage to provide a continous path leading to the nearest exit in accordance with 19.2.1.
D. Corrected 08/11/2014
E. Corrected 08/11/2014


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F. NEW August 12, 2014 at 9:10am while accompanied by the Director of Facilities the central Exit Stair (located across from the 3 elevator "lobbies" and the "west" stair are connected on the second floor by an "exit passageway". The central stair does not provide a continuous protected path to a "discharge" therefore it does not comply with 7.1.3.2.2, 19.2.2.7 for an exit passageway nor 7.2.6.3 for opening protection. The passageway is a "landing" that connects two stairs, therefore the Stair adjacent to the elevator lobbies is considered an interior discharge stair which does not discharge to grade.

A. Based on document review of plans dated 3/31/14 and based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that protected exit paths are not available at all times and that designated exit stairs lack an exit discharge in accordance with 7.7.1 or 7.7.2 of NFPA 101: Failure to maintain exit paths could result in delay of exiting and/or a fire within an exit enclosure.

Findings include

1. The 8th Floor elevator foyer of the Glen Oak Building is a required exit access corridor for the both ends of Glen Oak; it has access to one exit stair. Any other exit path from the space, to the north or to the south is locked. The elevator foyer/exit access corridor lacks two exit paths in accordance with 19.2.5.9.

2. Corrected 08/12/2014

A. CORRECTED 01/09/15.


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B. NEW : August 12, 2014 at 10:50am While accompanied by the provider's Director of Facilities: the exterior exit discharge from the "Southwest" stair (Third floor adjacent to Stretcher Shop) contains guardrails at the landing and the exterior stair leading to the "public way" which were observed to be in excess of 4" this does not comply with 7.2.2.4.6.(3).

C. New: August 12, 2014 at 10:50 am While accompanied by the provider's Director of Facilities: the threshold from the exit discharge door for "Southwest" stair to the concrete landing exceeds 1/2" and does not comply with 7.2.1.3 for floor level.

D. New August 12, 2014 at 1050am While accompanied by the provider's Director of Facilities: the exterior discharge concrete stairs did not provide a reliable means of egress and is not maintained to comply with 7.1.10.1.

E. New August 11, 2014 at 2:00pm While accompanied by the provider's Director of Facilities, the 5th floor means of egress corridor exits to the East into a "Call-in room" within the Glen Oak building. The Life Safety floor plans indicate a pair of cross corridor doors to the South of the "Call-in" room which are not present. The room is considered a business occupancy which is occupied less than 24/7. This condition does not comply with 19.2.5.9 for corridor access to an exit without passing through an intervening room.

A. Based on random observation during the survey walk-through, accompanied by two contractor foremen, the surveyor finds that exit access is not arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the building.

Findings include:

1. At 1:50 PM on April 8, 2014, on the Hamilton 8th floor adjacent to the elevators it was observed that the door which leads into the East/West building was locked on the Hamilton Building side. This location is identified as a horizontal exit with exit travel and exit signage identified in both directions on the life safety drawings dated 3-31-14. 19.2.2.2.4

2. At 1:47 PM on April 8, 2014, at the Hamilton 8th floor elevators it was observed that the elevator foyer is not a designated psychiatric area and is available to the public. It only has one unlocked exit path and so does not comply with 19.2.5.9.

A. Based on document review of plans dated 3/31/14 and based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that designated two hour fire barriers do not comply with 8.2.3 of NFPA 101 and NFPA 80. Failure to maintain designated fire barriers will allow fire and smoke to spread into adjacent fire compartments and/or buildings during a fire emergency.

Findings include:

1. CORRECTED 01/09/15.

2. 4th Floor North Corridor for the East/West Building: The "House" office has a 90 minute fire door, in a two hour wall, which opens into the Kitchen Storage to the west was held open by an unapproved device (wedge).

Update 01/09/15: The unapproved hold open device (door wedge) is still being used therefore the completion date of 08/11/14 for the above items is not met.

A. Corrected 08/11/2014


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B. Corrected 08/11/2014


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C. 1. Corrected 01/08/15:

2. New deficiency - 01/08/15: Crescent Pavilion: Based from direct observation during the walk-through with the facility director, identified horizontal exits in the south end of the Cresent Pavilion Wing are not equipped with the required pull stations
. Example: 8th Floor

A. Based on document review of plans dated3/31/14 and based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that designated two hour fire barriers do not comply with 8.2.3 of NFPA 101 and NFPA 80. Failure to maintain designated fire barriers will allow fire and smoke to spread into adjacent fire compartments and/or buildings during a fire emergency.

Findings include:

1. Corrected 08/12/2014

2. The 2nd Floor has a 90 minute fire doors at the Innovation Center. The door frame has an electronic strike receiver which was not positive latching. The provider was not able to demonstrate when the door latches.

Update 01/08/15: The 90 minute door at the Innovation Center did not positively latch during fire alarm activation, therefore did not meet the completion date of 05/27/14.

A. Corrected 8/12/14


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B. Based on random observation during the survey walk-through, accompanied by two contractor foremen, the surveyor finds that not all doors identified on the life safety drawings as horizontal exits are in compliance with the requirements of 7.2.4. This deficiency could cause patients, staff, or visitors to be not fully protected during a defend in place emergency.

Findings include:

1. Corrected 01/08/15

2. New deficiency - 01/08/15: Hamilton Pavilion 8th Floor Elevators: Based from direct observation during the walk-through with the facility director, identified horizontal exits lacked pull stations to meet the requirements of 9.6.2.3

A. Based on random observation during the survey walk-through, accompanied by two contractor foremen, the surveyor finds that 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 cited area by preventing them from safely exiting the building under fire conditions.

Findings include:

1. At 1:50 PM on April 8, 2014, on the Hamilton 8th floor adjacent to the elevators it was observed that the door which leads into East/West building was not provided with an exit sign. This location is identified as a horizontal exit on the life safety drawings dated 3-31-14. The horizontal exit does not comply with 7.2.4. 19.2.10.1

2. At 9:15 AM on April 9, 2014, on the Hamilton 4th floor it was observed that an exit sign was not provided over the cross corridor doors that lead to the Southwest Building. This location is identified as a horizontal exit on the life safety drawings dated 3-31-14. The horizontal exit does not comply with 7.2.4. 19.2.10.1

3. At 2:45 PM on April 10, 2014, on the Hamilton 3rd floor: The exit access corridor near the east wall of the CT Scan 1 has two paths of egress; the second path of egress lacks an exit sign near the CT Scan Room 2. This location is identified as a horizontal exit on the life safety drawings dated 3-31-14, the corridor is otherwise a dead end corridor. 19.2.10.1.

Based on the review of the facility's documents, including the plans provided for this survey dated 3/31/14 with multiple personnel present including the Director of Facilities and the Safety Director, the surveyors determined that the facility failed to maintain a fire plan for the protection of residents to provide a prompt and effective response in the event of a fire emergency in accordance with LSC, Section 19.7.2.1.

Findings include:

A. The information, including the plan dated 3/31/14, provided for this survey were not entirely accurate and did not correctly show the life safety buildings conditions observed.

1. Exit Passageways were not identified on plans

2. Not all suites are identified (including the size and boundary). Example: 2nd Floor Crescent Building: Recovery and Holding Area Suite is not identified on plans.

3. The identification of horizontal exits is not accurate and the symbols on plans used to identify the required direction of exit travel at the horizontal exits are not always accurate. (Example: symbol with exit in both directions may identify a door with no exit sign and or a door which is locked. One hour horizontal exits are also identified which do not exist or comply with any rules in NFPA 101.

4. Surveyor 07113 observes that the two smoke compartments identified on plans dated 3/31/14, are separated on paper by a one hour fire barrier and not a one hour smoke barrier in accordance with 19.3.7.3.

The surveyors find that the provider cannot comply with 19.1.1.3 without accurate life safety information.

Based on document review and random observation during the survey walk-through, accompanied by two contractor foremen, the surveyor finds that the facility ' s life safety drawings, dated 3-31-14, were not accurate as required to be a part of the Life Safety Plan required by 19.7.1.1. This deficiency could cause patients, staff, and visitors to not respond appropriately during a fire emergency.

Findings include:

A. Throughout the survey it was observed that there are so many designated horizontal exits shown on the life safety drawings, dated 3-31-14, that based on the symbols used it is not possible to determine where exit signage and fire alarm pull stations are truly required and what the required direction of exit travel is.

A Based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that fire alarm pull stations are not installed in accordance with NFPA 72. Failure to install fire alarm components in accordance with the codes could delay activation of the fire alarm system in a fire emergency.

Findings include:

1. The north extension of the 5th Floor Corridor on 5 East extends to a North Exit Stair. A fire alarm pull station was found in front of an abandoned elevator opening, well away from the North Stair. A fire alarm pull station was not installed within five feet of the exit in accordance with NFPA 72 1999 2-8.2.2.

2. The East Exit Stair on the 4th Floor of the East/West Building lacks a fire alarm pull station within five feet of the exit. (NFPA 72 1999 2-8.2.2)

3. Because a pattern was observed, of not having pull stations within five feet of each exit, was observed on multiple locations in the East/West Building and also in the Glen Oak Building, the surveyor expects to find similar conditions on all floors of these buildings.

A. 1. CORRECTED 01/09/15.


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B. 1. CORRECTED 01/09/15.


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Based on random observation during the survey walk-through, accompanied by two contractor foremen, the surveyor finds that the facility failed to provide a fire alarm system with approved components, devices or equipment installed according to NFPA 72. These deficiencies would affect all occupants in the event of a delay in fire alarm activation, notification, or function of devices controlled by the fire alarm.

Findings include:

C. Several cross corridor doors are identified as horizontal exits on the life safety drawings, dated 3-31-14, but are not equipped with fire alarm pull stations as required by 9.6.2.3 and NFPA 72 1999 2-8.2.2. Locations include, but are not limited to:

1. 8:00 AM on April 9, 2014 on 5th floor Hamilton, 2 pairs of doors to the Crescent Building, and 2 pairs of door to the Southwest Building.

2. 9:30 AM on April 9, 2014 on 4th floor Hamilton, 1 pair of doors to the Crescent Building, 2 pairs of doors to the Southwest Building, and 1 pair of doors to the East/West Building by elevators.

3. 10:15 AM on April 9, 2014 on 3rd floor Hamilton, 2 pairs of doors to the Emergency Department, 1 pair of doors to the East/West Building, and 2 pairs of doors to the Southwest Building.

A. Based on random observation on 4/09/14 through 4/11/14, with the Director of Facilities and the Safety Office present, the surveyor observed fire alarm devices which were not installed in accordance with NFPA 72 - 1999 and observed fire alarm devices required by 9.6.2.3 of NFPA 101 and NFPA 72 1999 4-3.2.2. were missing. Failure to install fire alarm components in accordance with the codes could delay activation of the fire alarm system in a fire emergency.

Findings include:

1. Glen Oak - A fire alarm pull station is installed on every floor on the corridor wall opposite the elevators. These pull stations are not located anywhere near an exit and exceed the requirements in NFPA 72.

a. A fire alarm pull station on every floor is
typically not installed within five feet
of the Glen Oak North Exit Stair.

b. Although the identification of horizontal
exits are confusing and in some cases
incorrectly identified on the Life Safety
Plan dated 3/31/14, the surveyor
observed 90 minute pairs of fire doors in
designated two hour fire barriers on
Floors 3-8. These doors are identified as
horizontal exits between Glen Oak and
the East/West Building. Fire alarm pull
stations are not installed on each side of
this designated horizontal exit doors,
within five feet of the doors, on every
floor.

c. The Life Safety Plan dated 3/31/14,
identify a Horizontal Exit between Glen
Oak and the Southwest Building on the
5th, 3rd and 2nd Floors. Fire alarm pull
stations are not installed within five feet
of these doors, on both sides of the
doors in accordance with NFPA 72.

A. Based on random observation on multiple days and based on fire alarm testing by the provider on the morning of 04/10/14, with the Director of Facilities and the Safety Office present, the surveyor observed fire alarm devices which were not installed and maintained in accordance with NFPA 72 - 1999 and the surveyor observed fire alarm devices required by NFPA 72 which were missing.

Findings include:

1. Corrected 08/11/2014
a. Corrected 08/11/2014

b. The plans dated 3/31/14 identify a Horizontal Exit between the Kitchen, between Hamilton and the Hamilton Annex. Fire alarm pull stations are not
installed within five feet of these doors, on one or both sides of the doors to comply with NFPA 72 1999 4-3.2.2.


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B. Corrected 08/11/2014

Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. These deficiencies could affect any patents, staff, or visitors in the building because effective notification of building occupants may not occur.

Findings include:

A. Corrected 01/09/15.

New Deficiency - 01/09/15: The Fourth Floor door at the north end of the Bridge to the Hamilton Building which is a designated horizontal exit as shown on the Life Safety Plan, was observed to lack a fire alarm pull station within 5'-0" of the door as required by 9.6.2.3. and NFPA 72 1999 2-8.2.2.

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. 1. CORRECTED 01/08/15.
2. CORRECTED 01/08/15.



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B. New August 12, 2014 at 10:50am While accompanied by the Director of Facilities, an exterior canopy above an exit discharge was observed which lacked sprinkler protection to comply with NFPA 13, 5-13.8.1. Location observed is the discharge from the "Southwest" Stair at the third floor adjacent to stretcher shop. The canopy extends more than 4' at one end is attached to the building and appears to be non combustible or limited combustible however the top of the canopy could not be determined.

A. Based on observation during the survey walk-through, on 4/11/14 with Director of Facilities and the Safety Officer present, the surveyor finds that the facility failed to maintain automatic sprinkler protection in accordance with the requirements of NFPA 101-2000, 19.3.5, NFPA 13-1999, Chapter 5 and NFPA 25-1998, 2-2.1.1. Failure to install and maintain sprinkler protection could result in partial coverage and spread of fire and smoke in a fire emergency.

Locations include but are not necessarily limited to:

1. Corrected 8/11/14
2. Corrected 8/11/14
3. Corrected 8/11/14
4. Corrected 8/11/14

The above condition is not detected and abated during monthly, quarterly and/or annual sprinkler inspections in accordance with NFPA 25.

A. Based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that HVAC systems are not installed and maintained in accordance with 4.5.7and 8.2.3.2.3 of NFPA 101 and with NFPA 90A.

Findings include

1. Corrected 08/12/14

2. Corrected 08/12/14

3. Corrected 01/08/15

New Deficiency- 01/08/15: Based from observation with the facilty Director and interview with the facility's HVAC contractor, the required fire dampers and access panels for the ductwork that penetrates the floor above and below which were not installed in the plane of the floor have been removed. Therefore the designated two hour fire rated floor above and below in Room 631 is not maintained to comply with 8.2.3.2.3 and NFPA 90A and 19.5.2.1.


4. a. CORRECTED 01/08/15.
b. CORRECTED 01/08/15.
5. a. CORRECTED 01/08/15.
b. CORRECTED 01/08/15.

6. The 5th Floor Mechanical Space, at the same location as Item 1 above, in the West Building was recently combined with a RO Water Room (dialysis). The mechanical room is not identified on plans and the plans identify a one hour corridor wall instead of a two hour fire rated shaft/corridor wall. Two corridor doors to this space are 3/4 hour fire doors instead of 1 1/2 hour B Label fire doors. The exhaust duct which passes through this space was not enclosed in a fire rated shaft. Instead fire dampers were installed at the floor penetration above and below. This condition does not comply with NFPA 90A 3-3.4.1. The fire damper at the floor penetration below lacked an access panel on 04/10/14 . The space only complies with NFPA 90A if the mechanical room is part of the shaft enclosure. Three ducts penetrate the corridor wall without fire dampers and the room does not comply with NFPA 90A 3-3.4.4.

Based on observation on the morning of 4/11/14, with the Director of Facilities, the Food Service Manager and the Safety Officer present, the surveyor finds that kitchen ventilation hood of the 3rd Floor Main Kitchen is not installed and/or maintained in accordance with NFPA 96 - 1998, ASHRAE Guidelines and State and/or National Food Service and Sanitation Regulations.

Findings include

1. The main cooking line is two cooking lines with two rows of appliances back to back with a common hood above. There are two rows of grease filters in the hood which are centered above both cooking lines. The filters are mounted in a horizontal position and are not installed at a 45 degree or greater angle in accordance with 3-2.5 of NFPA 96. The provider was not able to demonstrate have grease collection is installed in accordance with 3-2.6 and 3-2.7 of NFPA 96.

a. The provider lacked technical information which demonstrates how this hood is pre-engineered and how the filters are designed to accomplish the requirements of 3-2.5 and 1-3.5 (Alternate Methods) in accordance with NFPA 96.

b. The surveyor observed a two sided main cooking line which produced a lot of moisture from hot water and steam from cooking processes. The surveyor observed that some of this moisture was not going up the kitchen hood directly above and that the system make-up air did not appear to be working. The surveyor further observed grease and moisture dripping from the hood filters and from the stainless steel shroud below the filters.

Failure to maintain adequate ventilation could allow the build up of grease on all surfaces which could constitute a fire hazard .

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. At 1:25 PM on April 10, 2014, while accompanied by the provider's Electrician and HVAC Specialist: 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 (all Second Floor Surgical Department):

1. Corridor immediately north of Prep/Recovery Unit.

2. Corridor serving Operating Rooms 1, 2, 6, and 7.

3. Corridor serving Operating Rooms 3, 4, 8, and 9.

4. Corridor serving Operating Rooms 10 and 11.

Based on random observation during the survey walk-through, accompanied by two contractor foremen, the surveyor finds that 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. At 1:22 PM on April 9, 2014, on the 2nd floor Hamilton, 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 observed include:

1. The corridor that serves Operating Rooms 20, 21, and 22 and the corridor that serves the Sterile Processing suite.

A. Based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that Medical Gas Systems do not comply with NFPA 99- 1999.

Findings include

1 The 3rd Floor of the Glen Oak Building has an inpatient Dialysis Unit with oxygen, medical air and vacuum outlets at each patient station. The floor has oxygen, medical air and vacuum outlets in other outpatient treatment rooms on this floor. The oxygen shut off valves in the Dialysis room is located in the same room as the oxygen outlets and does not comply with NFPA 99, 4-3.1.2.3.

b. The provider was not able identify a zone valve which serves the medical air system for the 3rd Floor of Glen Oak in accordance with NFPA 99 4-3.1.3.2.

Update 01/09/15: The Plan of Correction (PoC) for the above item did not meet the completion date of 12/31/14.

A. Corrected 08/11/2014


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B. Based on random observation during the survey walk-through (and staff interview), the Construction Manager and HVAC person, not all medical gas piping systems are installed and maintained in accordance with NFPA 99. This deficiency could affect any patients in the cited area because the medical gas system could become compromised.

Findings include

1. 2nd Floor Crescent Building: On the afternoon of 04/10/14, the medical gas zone (shut-off) valves serving Holding and Recovery Suite 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).

A. Corrected 08/12/2014

B. Corrected 08/12/2014

C. 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:

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, 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, 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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A. Deleted 08/11/2014

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.

A. Based on random observation during the survey walk through while accompanied by the Electronics Technician, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

1. The Crescent building was equipped with transfer switches for each branch of emergency power, but several of the panels served from the branch transfer switches were serving mixed loads as shown by some of the following examples:

a) 7th floor panel R-1S-7-174 was not listed as a life safety or critical panel, but was serving corridor and exit lighting, (life safety loads), and nurse call and receptacle loads that are critical loads.

b) 6th floor panel R-1C-6-146 is a critical panel that was serving fire alarm equipment that is required to be served from the life safety branch of emergency power

c) 5th floor, the life safety panel was serving receptacles and nurse call that are required to be served from the critical branch of emergency power, and critical panel P-3C-5-112 was serving a modular cooling unit that is required to be served from the equipment branch panel if it is to be served from the emergency power system.

d) 4th floor critical panel R-1C-4-146 was serving the elevator cab lighting that is required by Section 517-32 of NFPA-72, to be served from the life safety branch panel.

e) 3rd floor panels R1C-3-346 was serving fire alarm that is required by Section 517-32 of NFPA-70, to be served by the life safety branch panel.

f) 2nd floor life safety panel R-1S-2-130 was serving nurse call and telecom equipment that Section 517-33 of NFPA-70, requires to be served from the critical branch of emergency power. Critical panel R-1C-2-114 was serving fire alarm and elevator lights.

g) 1st floor life safety panel in the main electric room was serving duct heaters in the training room which are not allowed on the life safety branch by Section 517-32 of NFPA-70.

Items listed above are examples of the mixed loads served by the different branches of emergency power but do not constitute a full list of infractions. The surveyor observed a pattern in multiple buildings and similar problems are expected in all buildings of the hospital.

Based on random observation during the survey walk through while accompanied by the Electrical System Analyst and the Electronics Technician, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

1. The Glen Oak building was equipped with transfer switches for each branch of emergency power, but several of the panels served from the branch transfer switches were serving mixed loads as shown by some of the following examples:

a) 9th floor life safety panel E-LS-9-1was serving the nurse call system which is required by Section 517-33 of NFPA-70 to be served from the critical branch of emergency power.

b) 7th floor life safety panel ELS-7 was serving a clock and receptacles which are not allowed to be served from the life safety branch by Section 517-32 of NFPA-70.

c) 5th floor life safety panel L5 was serving a stairwell heater.

Items listed above are examples of the mixed loads served by the different branches of emergency power but do not constitute a full list of infractions. The surveyor observed a pattern in multiple buildings and similar problems are expected in all buildings of the hospital.

Based on random observation during the survey walk through while accompanied by the Electrical System Analyst and the Electronics Technician, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

1. The Hamilton building was equipped with transfer switches for each branch of emergency power, but several of the panels served from the branch transfer switches were serving mixed loads as shown by some of the following examples:

a) 5th floor critical panel CR-5 was serving elevator cab lighting which is required by Section 517-32 of NFPA-70 to be served from the life safety branch of emergency power.

b) 4th floor life safety panel LS-4 was serving a nurses station which is required by Section 517-33 of NFPA-70 to be served from the critical branch of emergency power.

c) 3rd floor panel in the day light traffic room was not labeled and was serving a mixture of emergency loads/

d) 2nd floor emergency panel EM2A was serving a mixture of emergency loads.

e) 1st floor panel 18205 in the mail room was serving a mixture of emergency loads, and panels EM1A, EM1B, and 1H14 in the main electrical room were serving a mixture of emergency loads.

Items listed above are examples of the mixed loads served by the different branches of emergency power but do not constitute a full list of infractions. The surveyor observed a pattern in multiple buildings and similar problems are expected in all buildings of the hospital.

Based on random observation during the survey walk through while accompanied by the Electrical System Analyst and the Electronics Technician, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

1. The Southwest building was equipped with transfer switches for each branch of emergency power, but several of the panels served from the branch transfer switches were serving mixed loads as shown by some of the following examples:

a) 5th floor critical panel R1C-5-1A was serving a fire alarm NAC panel that is required by Section 517-32 of NFPA-70 to be served from the life safety branch of emergency power

b) 4th floor emergency panels E4A and E4B were serving mixed emergency loads.

c) 3rd floor emergency panels 3SW5, 3SW8, 3SW12, and 3SW17 serve a mixture of emergency loads.

d) 2nd floor emergency panel 2SW3 was serving a mixture of emergency loads.

e) 1st floor emergency panels 1SW1 and EM1 were serving a mixture of emergency loads.

Items listed above are examples of the mixed loads served by the different branches of emergency power but do not constitute a full list of infractions. The surveyor observed a pattern in multiple buildings and similar problems are expected in all buildings of the hospital.

A. Based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that electrical systems and materials do not comply with NFPA 70- 1999. Failure to properly identify electrical panels could result in a delay in locating and shut off electrical circuits when necessary in an emergency.

Findings include

1. Based on random observation through the Glen Oak Building the surveyor finds that data cables are resting on the ceiling or are draped over duct work, conduit, sprinkler piping, etc. above ceilings. These date cables are not properly supported in accordance with NFPA 70 - 1999, 800-6. Example 7th Floor - South open plan office area.

2. Corrected 08/12/2014

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. This deficiency could affect any patients being treated in the cited area because emergency power may not be available under certain conditions, or may affect any patients, staff, or visitors in the building because the fire alarm system could become compromised.

Findings include:

A. At 1:45 PM on April 10, 2014, while accompanied by the provider's Electrician and HVAC Specialist: The electrical receptacles in Second Floor Operating Room 6 which are served by the building's Emergency Electrical System were observed to not be labeled as to panel and circuit number as required by NFPA 70 1999 517-19(a).


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B. Based on random observation during the survey walk through while accompanied by the Electrical Systems Analyst and the Electronics Technician, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility using the elevator during a power outage, and anybody working on elevator equipment.

Findings include:

1. The elevator cab lights were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32, and they were not equipped with a disconnect in the elevator equipment room in accordance with NFPA-70, Section 620-53.

2. Corrected 08/11/14.


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C. Based on random observation during the survey walk-through, accompanied by two contractor foremen, the surveyor finds that the facility failed to install electrical wiring in accordance with NFPA 101, 2000 Edition, Section 9.1.2 and NFPA 70, 1999 Edition, National Electrical Code. This deficiency could affect the performance and stability of the ceiling system.

Findings include:

1. At 11:07 AM on April 9, 2014, on Southwest Building 3rd floor at the cross corridor doors into the Hamilton Building near X-Ray Room 7, a large number of electrical data cables were laying directly on the suspended ceiling. NFPA 70 1999 800-6

A. Based on random observation with the Construction Manager and HVAC person present the surveyor finds that electrical installations and materials do not comply with NFPA 70-1999:

Findings include but are not limited to:

1. 6th Floor Crescent Building : Electrical conduits and cable wirings were observed laid above the ceiling that are not properly supported to comply with NFPA 70 1999 300-11 Subpart (a). This condition exists at the connecting corridor between Crescent and Hamilton Building.

2. Corrected 08/11/2014


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B. Based on random observation during the survey walk through while accompanied by the electronics technician, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

1. The elevator cab lights were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32, and they were not equipped with a disconnect in the elevator equipment room in accordance with NFPA-70, Section 620-53.

2. The recovery area on the second floor, and the Pediatric room headwalls were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-18, and 517-19.

3. Panel identification and panel schedules are not accurate or have not been updated to meet the requirements of NFPA-70, Section 110-22, and Section 384-13.

Based on random observation during the survey walk-through, accompanied by two contractor foremen, the surveyor finds that the facility failed to install electrical wiring in accordance with NFPA 101, 2000 Edition, Section 9.1.2 and NFPA 70, 1999 Edition, National Electrical Code. This deficiency could affect the performance and stability of the ceiling system.

Findings include:

1. At 9:15 AM on April 9, 2014, on Hamilton 4th floor at the cross corridor doors into the Crescent Building, a large number of electrical data cables were laying directly on the suspended ceiling. NFPA 70 1999 800-6

A. 1. CORRECTED 01/08/2015.
2. CORRECTED 01/08/2015.

A. Based on random observation during the survey walk through while accompanied by the electronics technician, the surveyor found that the elevators did not meet all of the requirements of ANSI/ASME A17.3. This could affect any occupants of the facility using the elevator if proper safety equipment is not installed on each elevator.

Findings include:

1. CORRECTED 01/08/15.

2. The elevators were not equipped with elevator recall initiated by smoke detectors in the elevator machine rooms, and lobbies in accordance with ANSI A17.1/A17.3.