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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.

A. CORRECTED 01/09/15.


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B. Corrected 06/18/2015
C. Corrected 2/19/16
D. Corrected 06/18/2015

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.

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. Corrected 06/18/2015

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

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.

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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.

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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.

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. Corrected 2/19/16
2. Corrected 08/11/14.


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C. Corrected 2/19/16

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. 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.