HospitalInspections.org

K-18
Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. This practice affected all residents, staff, and visitors of the facility. The facility capacity is 227 and the census was 69.
Findings include:
Observation on 9-11-12 between 8:19 am and 1:37 pm on the 3rd floor Patient Tower revealed:
1. The small inactive leaf on Patient Door 337 failed to provide an automatic flush bolt to provide positive latching.
2. The small inactive leaf on Patient Door 338 failed to provide an automatic flush bolt to provide positive latching.
3. Facility failed to provide a policy for the closing of the Patient doors which had a smaller inactive leaf during a fire emergency.
4. Patient Door 334 held open with a trash can, when removed the door closed.
Observation on 9-11-12 at 11:19 am on the 1st Floor revealed:
5. The temporary construction door leading into the CT Room Niche failed to latch, black tape placed over the strike plate.
Observation on 9-12-12 at 9:12 am on the 1st Floor ED area revealed:
6. The Doctor ' s Office door near Exam 11 failed to engage the door frame.

During an interview on all dates and each time of observations, Maintenance H confirmed the findings.

NFPA Standard:
The minimum clear width for doors in the means of egress from sleeping rooms; diagnostic and treatment areas, such as x-ray, surgery, or physical therapy; and nursery rooms shall be as follows:
(1) Hospitals and nursing homes - 41.5 in. (105 cm)
(2) Psychiatric hospitals and limited care facilities - 32 in. (81 cm)
Exception No. 1:
Doors that are located so as not to be subject to use by any health care occupant shall be not less than 32 in. (81 cm) in clear width.
Exception No. 2:
Doors in exit stair enclosures shall be not less than 32 in. (81 cm) in clear width.
Exception No. 3:
Doors serving newborn nurseries shall be not less than 32 in. (81 cm) in clear width.
Exception No. 4:
Where a pair of doors is provided, not less than one of the doors shall provide not less than a 32-in. (81-cm) clear width opening and a rabbet, bevel, or astragal shall be provided at the meeting edge. The inactive leaf shall have an automatic flush bolt to provide positive latching.
2000 NFPA 101, 18.2.3.5

Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 18.3.6.3.1, 18.3.6.2 and 18.3.6.3

K-22
Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 69 of 227.

Findings are:
Observations during the facility tour on 9/11/12, from 9:09 am to 9:34 am revealed:
1. An exit sign failed to be installed near Room 219 on the 2nd Floor of the Bed Tower to direct occupants east.
2. An exit sign failed to be installed near Room 228 on the 2nd Floor of the Bed Tower so that a sign was visible when facing west.
In an interview conducted at the time of observations (9/11/12, from 9:09 am to 9:34 am), Maintenance D confirmed that exit signs were not visible in these areas.

K-25
Based on observation and interview the facility failed to provide smoke barriers with at least ? hour fire resistance rating constructed in accordance with NFPA 101, 8.3, above smoke doors on the 3rd floor. The facility census was 60 patients

Findings are:
Observation on 9-11-12 at 10:19 am and 10:47 am on the 3rd floor Patient Tower revealed:
1. Unsealed penetration around a 3 inch conduit and two ? inch conduits above ceiling tiles above the double smoke doors 3B550 across from room 306 next to Triage Room.
2. Unsealed penetrations around three 3 inch cable pipes above ceiling tiles above the double smoke doors 3A153 next to room 330.
During an interview on 9-11-12 at both times of observations, Maintenance H confirmed the unsealed penetrations.
NFPA Standard:
Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

K27
Based on observation and interview, the facility failed to provide doors in smoke barriers to create a barrier to resist the passage of smoke on the 3rd floor in the Patient Tower and the 1st floor OR area. This failure would allow smoke to migrate from one smoke compartment to another in the facility. Facility census was 60 patients.

Findings are:
Observation on 9-11-12 at 9:28 am on the 3rd floor Patient Tower revealed:
1. 3A550 double doors had a gap at the meeting edge greater than 1/8 inch.
During an interview on 9-11-12 at 9:28 am, Maintenance H confirmed the gap between the doors.
Observation on 9-11-12 at 2:58 pm on the 1st floor OR area revealed:
2. W1671 double doors had a gap at the meeting edge greater than 1/8 inch.
During an interview on 9-11-12 at 2:58 pm, Maintenance D confirmed the gap between the doors.
Observation through testing during the survey on 09-11-12 at 11:41 am, of the Bed Tower 1st floor revealed that the smoke barrier doors IB-154 did not close entirely to provide a smoke tight fit.
Interview with Maintenance " C " at eh time of observation confirmed the doors did not close properly.

K-29
Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for smoke and fire to spread into the egress corridors. Facility census was 69 of 227.

Findings are:
Observation during the facility tour on 9/11/12, at 11:09 am revealed the facility failed to seal two small holes in the corridor wall above the Bed Tower Soiled Linen 1B-222 door.
In an interview conducted at the time of observation, (9/11/12, at 11:09 am), Maintenance D acknowledged the findings.
Observations on 9-11-12 at 8:12 am and 9:12 am on the 3rd floor Patient Tower revealed:
1. The double doors to a storage area within 3 of 5 LDR rooms equipped with closures failed to close and latch within the door frames.
2. Facility failed to provide a self-closing device on Patient Room 332 door used as a storage room.
Observations on 9-11-12 between 2:16 pm and 4:30 pm on 1st floor revealed:
3. The facility failed to provide latching devices on the fire rated double doors leading to the Ambulance Bay.
4. Unsealed penetrations above the ceiling tiles in the Hypobaric Chamber room, approximately 3 feet south of the door on the east wall around numerous pipes.
5. The facility failed to provide 1-hour fire rated doors to the Hypobaric Chamber room.
6. The south door in the Hypobaric Chamber room provided a turn lock on the closure.
Observations on 9-11-12 between 2:16 pm and 4:30 pm on 1st floor OR area revealed:
7. The Pump room/storage room in the OR area failed to provide latching device.
8. Housekeeping room door W1070 failed to latch, hitting frame.
9. Unsealed hole in door W1071 in the OR area.
10. OR 2 used as a storage room, the double doors failed to provide latching devices.
Observations on 9-12-12 between 9:06 am and 9:18 am on 1st floor revealed:
11. Electrical Room Door W1174 in the ED area failed to latch, hitting frame.
12. The door to the old Trauma Coordinator office which was used as a storage room, failed to provide a self-closing device and latching hardware.
13. The door to the Medication Room in ED which was on a self-closure failed to engage the door frame.
Observations on 9-12-12 at 12:16 pm on 4st floor revealed:
14. 5 gallon plastic water jug holding open the 1 ? hour fire rated door 4A302.2.

During an interview on each day and at each time of observation, Maintenance H and D confirmed the findings.
Observation during the survey on 09-10-12 at 3:30 pm, of the East Campus revealed Voids around electrical conduits in the 4TH floor center electrical room.
Interview with Maintenance " C " at the time of observance confirmed the voids.
Observation during the survey on 09-11-12 at 02:11 pm, of the MOB West revealed the door to the Biohazard would not latch tightly in its frame.
Interview with Maintenance " C " at the time of observation confirmed the door would not latch.

NFPA Standard:
Hypobaric chambers and all ancillary service equipment shall be housed in fire-resistant construction of not less than 1-hour classification that shall be a building either isolated from other buildings or separated from contiguous construction by 1-hour noncombustible (under standard atmospheric conditions) wall construction. 1999 NFPA 99B, 3-1.1

If there are connecting doors through such common walls of contiguity, they shall be at least B label, 1-hour fire doors. All construction and finish materials shall be noncombustible under standard atmospheric conditions. 1999 NFPA 99B, 3-1.1.1

K-33
Based on observation and staff interview, the facility failed to penetrate 2 of 3 of the new Bed Tower stair enclosures with the items only allowed by NFPA 101, 7.1.3.2.1(e). This condition had the potential to allow smoke to enter the exit stairwells. Facility census was 69 of 227.

Findings are:
Observations during the facility tour on 9/11/12, from 8:34 am to 8:37 am revealed:
1. The East Bed Tower Stairwell failed to have utilities such as an elevator sump pump discharge pipe and a condensate pipe separated from the stair enclosure that passed through the enclosure.
2. The Center Bed Tower Stairwell failed to have utilities such as water and steam pipes separated from the stair enclosure that passed through the enclosure.
In an interview conducted at the time of observation, (9/11/12, from 8:34 am to 8:37 am), Maintenance D acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.1.3.2.1(e) Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.

K-38
Based on observation and interview, the facility failed to post the delayed egress signage on the 3rd floor OB stair tower door and failed to provide documentation for the approval of a 30 second delay. This deficient practice would cause confusion and delay egress. The facility census was 60 patients.

Findings are:
Observations on 9-11-12 at 8:38 am revealed the facility failed to post delayed egress signage on the magnetically locked 3rd floor stair tower door 3BO98C. When tested the door released in 30 seconds.

During an interview on 9-11-12 at 8:38 pm, Maintenance H confirmed the lack signage and failed to provide documentation for the approval of 30 second delay in lieu of 15 seconds.
NFPA Standard:
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, provided that the following criteria are met: doors shall unlock upon actuation of an approved, supervised automatic sprinkler system or any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system; the doors shall unlock upon loss of power; an irreversible process shall release the lock within 15 seconds upon application of a force not to exceed 15 pounds nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only; on the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch wide on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. 2000 NFPA 101, 7.2.1.6.1

Based on observation, staff interview and record review, this facility is not providing an all-weather surface from each exit to a public way (an area of safety) or providing a key for every staff member to carry for locked doors within the path of egress, affecting all occupants of the facility. This facility has a capacity of 227 with a census of 69 residents. Findings include:
During the survey of the West Campus on 09-12-12 between 02:00 pm and 03:00 pm, observation revealed the exit discharge passageway did not extend to the public way for the following exits W1228 and W1229.
Interview with Maintenance " E " confirmed the Exit ways did not extend to the public way.
NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

NFPA Standard: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1

K-44
Based on observation and staff interview, the facility failed to maintain two-hour fire barriers of horizontal exits. This condition had the potential to allow smoke and fire to migrate into separate buildings. Facility census was 69 of 227.

Findings are:
Observation during the facility tour on 9/11/12, from 9:33 am to 9:44 am revealed:
1. Two penetrations failed to be sealed on the new side above the Bed Tower W617 Fire Doors.
2. A penetration failed to be sealed on the west side of the Bed Tower 2A-154 Fire Doors.
In an interview conducted at the time of observation, (9/11/12, from 9:33 am to 9:44 am), Maintenance D acknowledged the findings.

K-45
Based on observation and interview the facility failed to maintain the exit discharge lighting so that the failure of one bulb would not leave the path from the facility to the public way in darkness. This deficient practice affects all occupants of the building. This facility has a capacity of 227 and a census of 69 residents.
Findings include:
During the survey of the West Campus on 09-12-12 between 02:00 pm and 03:00 pm, observation and interview revealed the following Exit Discharges to have only one - one bulb lighting fixture or none at all W1234,W1002,W1238,W1188,W1184,W1162,W1229,W1228,W1224 and W1236
Interview with Maintenance " E " at the time of findings confirmed the lack of the required two bulb lighting.
During the survey of the Bed Towers on 09-12-12 between 03:00 pm and 03:30 pm, observation and interview revealed the following Exit Discharges to have only one - one bulb lighting fixture.
1B-553-2 1A-098A-1
Interview with Maintenance " E " at the time of findings confirmed the lack of the required two bulb lighting.

During the survey of the East Campus on 09-10-12 at 02:40 pm, observation and interview revealed the following Exit Discharge to have only one - one bulb lighting fixture.
#2 Stairwell Exit Discharge
Interview with Maintenance " D " at the time of findings confirmed the lack of the required two bulb lighting

K-46
Based on observations and interview the facility failed to verify the operation of the battery operated emergency light in 1 of 2 C-Section Rooms. This deficient practice could affect the patient in the event of a power failure. The facility had a census of 60 patients.

Findings are:
Observations on 9-11-12 at 8:04 am revealed the battery operated emergency light in 1 of 2 C-Section Rooms was blinking a red light five times in sequence. The battery operated emergency light in the other C-Section Room was green.

During an interview on 9-11-12 at 8:04 am, Maintenance G failed to confirm that the emergency light blinking red in 1 of 2 C-Section rooms was operational. And failed to provide documentation of what the blinking light indicated.

During the survey of the West Campus on 09-12-12 between 02:00 pm and 03:00 pm, observation and interview revealed the pathway from Exit W1224 to the Point of Safety was void Emergency Lighting.
Interview at the time of finding with Maintenance " E " confirmed the lack of emergency lighting.
NFPA Standard:
The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101, 7.9.3

K-47
Based on observation and interview, the facility failed to provide exit signs to indicate the continuous path of egress on the 3rd floor of the Patient Tower. This deficient practice affected all patients, staff and visitors that use the OB and Womens/Childrens Wings on the 3rd floor. The facility census was 60 patients.

Findings are:
Observations on 9-11-12 at 8:47 am and 9:00 am, on 3rd floor Patient Tower revealed:
1. While standing in the corridor outside Room 320 looking south, an exit sign could not be seen to indicate the second required exit.
2. While standing in the corridor outside Room 326 looking south, an exit sign could not be seen to indicate the second required exit.

During an interview on 9-11-12 at 8:47 am and 9:00 am, Maintenance H confirmed the second exit sign could not be seen.
Observation during the survey on 09-10-12 at 14:02 pm, of the East Campus revealed the lack of an exit sign directing to the exit at the south end of the Intensive Behavioral Health Unit.
Interview with Maintenance " D " at the time of observation confirmed the lack of the sign.
Observation during the survey on 09-11-12 at 11:15 am, of the Bed Tower 1st floor revealed the lack of an exit sign in the corridor by the ICU room 10 and the lack of a double faced exit sign in the corridor by the ICU room 8.
Interview with Maintenance " C " at the time of observation confirmed the lack of exit signs.

K51
Based on observations and interview the facility failed to provide fire alarm devices with a visual illumination to be located in the operating rooms of the facility. Not providing the visual lighting could cause a fire emergency to go undetected in those rooms of the facility because of the inability to hear the alarm device. The facility had a census of 60 patients.

Findings are:
Observations during the fire alarm testing on 9-12-12 between 10:00 am and 12:30 pm on 3rd Floor Patient Tower and the OR area revealed:
1. Facility failed to provide a visual and audible fire alarm device in the Surgery sleep room.
2. Facility failed to provide visual fire alarm notification devices in the OR ' s of the facility.
3. The fire alarm sound could not be heard within an unoccupied OR.
4. The facility failed to provide audible or visual devices in the Sterile Processing Restroom and Locker Room.

During an interview on 9-12-12 during the fire alarm test, Maintenance H and D confirmed the findings.
NFPA Standard:
Means of egress shall have signs in accordance with Section 7.10. 2000, NFPA, 18.2.10.1
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. 2000, NFPA, 7.10.1.2


Based on observation and staff interview, the facility failed to install the fire alarm system in accordance with NFPA 72. This condition created the potential that the fire alarm would fail to effectively alert occupants. Facility census was 69 of 227.

Findings are:
Observations during the facility tour on 9/11/12, from 8:18 am to 9/12/12, at 10:24 am revealed:
1. A fire alarm strobe failed to be installed within fifteen feet of the Ground Level Bed Tower fire doors LB-551 on the west side of the doors.
2. A fire alarm strobe failed to be installed within fifteen feet of the 2nd Floor Bed Tower fire doors 2B552 on the east side of the doors.
3. A fire alarm strobe failed to be installed within fifteen feet of the 2nd Floor Bed Tower fire doors 2A593 on the east side of the doors.
4. A fire alarm strobe failed to be installed within fifteen feet of the 2nd Floor Bed Tower fire doors 2A154 near Room 227.
5. Fire alarm strobes failed to be synced in the Ground Level Bed Tower Mechanical Room.
6. Fire alarm strobes failed to be synced in the Ground Level Bed Tower Dining Room.
7. A fire alarm notification device failed to be installed in the new West Campus, 1st Floor Hyperbaric Room.
In an interview conducted at the times of observation, (9/11/12, from 8:18 am to 9/12/12, at 10:24 am), Maintenance B acknowledged the findings.
During the survey on 09-12-12 of the West Campus 2nd floor at 04:25 pm, the Hospitalist sleeping room was observed to be void the required Single Station Smoke detection and Audio/Visual notification of the facility Fire Alarm System.
Interview with Maintenance " A " at the time of observation confirmed the lack of smoke detection and Audio/Visual notification.

Actual NFPA Standards:
NFPA 72, 4-4.4.2.2*
Visible notification appliances shall be located not more than 15 ft (4.57 m) from the end of the corridor with a separation not greater than 100 ft (30.4 m) between appliances. If there is an interruption of the concentrated viewing path, such as a fire door, an elevation change, or any other obstruction, the area shall be treated as a separate corridor.

NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.

K-56
Based on observation and interview the facility failed to install automatic sprinkler protection to provide complete coverage for all portions of the building in accordance with NFPA 13 (sprinkler code) in the new enclosed Emergency Department Entry. This deficient practice would allow fire and smoke spread. The facility census was 60 patients.

Findings are:
Observations on 9-11-12 at 11:16 am revealed the facility failed to provide sprinkler protection in the newly constructed enclosed Emergency Department Entry.

During an interview on 9-11-12 at 11:16 am, Maintenance H confirmed the facility failed to provide sprinkler protection.
Observations during the facility tour on 9/11/12 from 7:51 am to 9/12/12, at 4:00 pm revealed:
1. An upright sprinkler head in the Lower Level Bed Tower Electrical Room failed to be installed so that an electrical conduit would not obstruct the head near a junction box at the ceiling labeled B1LH5.
2. Sprinkler heads in the Bed Tower LA17 Basement Server Room failed to be installed so that a water main and conduit would not obstruct the heads.
3. 3 of 3 stairwells in the Bed Tower failed to have sprinkler protection installed at the top and bottom of the stairs.
4. All fire department connections on the Emergency Room Road failed to be labeled as to the areas they served.
5. A sprinkler escutcheon failed to be installed in the West Campus, 1st Floor Wound Center Communications Room.
In an interview conducted at the times of observations, (9/11/12 from 7:51 am to 9/12/12, at 4:00 pm), Maintenance D acknowledged the findings.

Actual NFPA Standards:
NFPA Standard:
Where required by 18.1.61 health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 2000 NFPA 101, 18.3.5
NFPA 13, 5-13.3.2
In noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft.

NFPA 13, 5-1* Basic Requirements.
5-1.1*
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

NFPA 25, 9-7 Fire Department Connections.
9-7.1
Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

K-69
Based on observation and staff interview, the facility failed to provide an approved method to return all wheeled appliances to an approved design location under the range hood suppression system in the Kitchen. This condition had the potential for a fire to start on an appliance and not be suppressed by the suppression system due to the appliance being out of the approved location. Facility census was 69 of 227.

Findings are:
Observation during the facility tour on 9/11/12, at 8:03 am revealed the griddle failed to be centered under the suppression system nozzles during the survey. The facility failed to provide an approved method to have the griddle and all wheeled appliances protected by the suppression system returned to the approved location.
In an interview conducted at the time of observation, (9/11/12, at 8:03 am), Maintenance D acknowledged the findings.

Actual NFPA Standard:
NFPA 96, 12.1.2.3.1 An approved method shall be provided that will ensure that the appliance is returned to an approved design location.

K-72
Based on observation and interview, the facility failed to maintain the means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice affected all patients, visitors and staff that use exit corridor near the ED check-in area. Facility census was 60 patients.

Findings are:
Observations on 9-10-12 and 9-11-12 at various times revealed folding chairs, wheel chairs and movable walls in the corridor near the ED check in which narrowed the corridor width.

During an interview on each day and at various times, Maintenance H confirmed the items in the corridor.

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

K-78
Based on record review and staff interview, the facility failed to maintain humidity levels at 35% or greater at times of operations in 5 of 5 Operating Rooms. This condition increased the potential of the ignition of flammable germicide used during operations. Facility census was 69 of 227.

Findings are:
Record review of operating room humidity logs revealed records were only available up to June of 2012. Humidity levels failed to be maintained at 35% or greater on various dates and times. Records of humidity levels prior to June 2012 were incomplete.
In an interview conducted at the time of record review, (9/12/12, at 2:40 pm), Maintenance D acknowledged the findings.

K-106
Based on Observation and interview the facility failed to provide a Type I Essential Electrical System in the East Campus throughout the facility. A new generator and distribution system had been installed in 2009 that included all three branches of a Type I Essential Electrical System however this system existed only on the fourth floor. The remainder of the facility has only a Type III Essential Electrical System. This deficient practice would affect all residents, staff and visitors of the facility in the event of an emergency. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 8:35am revealed that there was a new emergency distribution system installed in the facility and it was only taken to the remodeled area of the fourth floor. The remaining systems were all just connected to the critical branch of the new system. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.

K-130
Based on observations and documentation review the facility failed to maintain and test the Line Isolation Monitor (LIM) per 1999 NFPA 99. This deficient practice would affect the operation of the LIM during a medical procedure and the patient. Facility census was 60 patients.

Findings are:
Observations on 9-11-12 at 2:47 pm revealed the facility failed to provide LIM or GFCI outlets in functional OR ' s. A LIM was located in the nonfunctional OR 2 which was being used as a storage room.

During an interview on 9-11-12 at 2:27 pm, Maintenance D failed to confirm the testing of the LIM.

Documentation review on 9-17-12 confirmed the facility failed to maintain the LIM on a monthly basis.

NFPA Standard:
1999 NFPA 99, 3-3.3.4.2 Line Isolation Monitor Tests.
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.
Based on Observation and interview the facility failed to provide a safe means of filling or transferring fuel to the Generator fuel supply in the North Medical office in accordance with the requirements of NFPA 37/6.5.4. This deficient practice has the potential to affect all occupants of the facility. The facility capacity is 227 and the census is 60.
Findings Include:
Observation on September 18, 2012 at 1:17pm revealed that there was no overflow line, high level alarm or high-level automatic shutoff to the fuel filling line at generator fuel supply tank. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.

NFPA Standard:
6.5.4 Fuel tanks supplied by pumps shall be provided with all of the following:
(1) An overflow line
(2) A high-level alarm
(3) A high-level automatic shutoff

K-130 West Medical Office Building
Based on Observation and interview the facility failed to have the Level 2 emergency generator installed in accordance with NFPA 110, 2002 edition by not providing emergency lighting in the area of the emergency generator and by not having an emergency generator shut down switch outside the area of the generator. This deficient practice has the potential to affect all occupants of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 1:17pm revealed that there was no emergency lighting in the area of the emergency generator in the mechanical room of the third floor. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 110, 2002ed. 7.3 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
Observation on September 18, 2012 at 1:18pm revealed that the emergency shutdown switch for the emergency generator was located in the same room as the generator and would not allow for safe shutdown of the emergency generator in the case of fire or other emergency involving the generator itself. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 110, 2002ed. 5.6.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

K130 NORTH MEDICAL OFFICE BUILDING
Based on Observation and interview the facility failed to have the Level 1 emergency generator installed in accordance with NFPA 110, 2002 edition by not having the generator installed in a separate room separated by a minimum of two-hour fire-rated construction, by not providing emergency lighting in the area of the emergency generator and by not having an emergency generator shut down switch outside the area of the generator. This deficient practice has the potential to affect all occupants of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 1:32pm revealed that the emergency generator was installed in a room with only a one-hour fire protection rating with just one layer of fire-rated drywall on each side of the metal stud framing and doors with only a one-hour fire rating. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 110, 2002ed. 7.2 The EPS shall be installed in a separate room for Level 1 installations. EPSS equipment shall be permitted to be installed in this room. The room shall have a minimum 2-hour fire rating or be located in an adequate enclosure located outside the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local building codes. No other equipment, including architectural appurtenances, except those that serve this space, shall be permitted in this room.
Observation on September 18, 2012 at 1:36pm revealed that there was no emergency lighting in the area of the emergency generator in the generator room of the third floor. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 110, 2002ed. 7.3 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
Observation on September 18, 2012 at 1:34pm revealed that the emergency shutdown switch for the emergency generator was located in the same room as the generator and would not allow for safe shutdown of the emergency generator in the case of fire or other emergency involving the generator itself. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 110, 2002ed. 5.6.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

K130 WEST CAMPUS (EXISTING)
Based on observation and interview the facility failed to maintain the line isolation panels in the operating rooms by not testing them on a monthly basis. This deficient practice has the potential to affect all patients and staff in the operating rooms by not being able to detect dangerous electrical levels. The facility capacity is 227 and the census is 60.
Findings are:
Observations on September 18, 2012 between 2:30pm and 3:00pm revealed that there were line isolation panels in 4 of the 6 current operating rooms and that the signal devices on all panels had been silenced so as not to alert staff in the event of abnormal conditions. When asked about the panels and monthly testing I was advised that they were not testing the panels and a couple panels has the silence switch broken so as to be not operable. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 99, 199ed. 3-3.3.4.2 Line Isolation Monitor Tests. The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch.

K130 EAST CAMPUS (EXISTING)
Based on Observation and interview the facility failed to have the Level 1 emergency generator installed in accordance with NFPA 110, 2002 by not providing emergency lighting in the area of the emergency generator and by not having an emergency generator shut down switch outside the area of the generator. This deficient practice has the potential to affect all occupants of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 8:32am revealed that there was no emergency lighting installed in the generator enclosure. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 110, 2002ed. 7.3 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

K-145 NORTH MEDICAL OFFICE BUILDING
Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 1:44pm revealed that there were the following non-Life Safety loads connected to the Life Safety branch panel PLSPL; (11) Door Holder 2100, AHU lights and AHU Humidifiers. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 1:54pm revealed that there were the following non-critical loads connected to the Critical branch panel 1CL1; (46) VAV Controls, (48) VAV Controls, (50) Auto Door, (52) AC-1. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
K-145 WEST BED TOWERS (NEW)
Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 17, 2012 at 11:00am revealed that the Critical branch panel ABCL1 contained the following non-critical loads; (1) ELEV PIT LTS S-1, S-2, (2) ELEV PIT LTS P-1, P-2, (3) ELEV PIT REC S-1, S-2, (4) ELEV PIT REC P-1, P-2, (5) ELEV PIT SUMP PUMP S-1, S-2, (6) ELEV PIT SUMP PUMP P-1, P-2, (7) ELEV PIT LTS P-3, (9) ELEV PIT REC P-3, (11) ELEV PIT SUMP PUMP P-3. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 11:12am revealed that there were the following equipment system loads connected to the Life Safety branch panel BBLL; (10) Pneumatic Tube Sorters, (11) Control Panels Pump and Chiller Rooms, (12) Pneumatic Tube Air pump. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 11:40am revealed that there were the following non-life safety loads connected to the Life Safety branch panel B1LL; (13) Well Rec. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 2:06pm revealed that there were the following Life Safety loads connected to the Critical branch panel APCL1; (18) Shunt P1 & P2 Elevator. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.

K145 West Campus
Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 17, 2012 at 2:34pm revealed that all the loads connected to the Critical branch panel BCL1 were not critical loads but were all equipment loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:02pm revealed that there were the following non-critical loads connected to the Critical branch panel BCL2; (1) NE Shop Outlet, (3) Main DDC Plugs in Maint. Computer Room, (5) Chiller Control DDC Panel, (7) Fuel Oil Shed, (8) Boiler Fuel Pump, (12) Simplex Fuel Monitor in Office, (13) MOB North Boiler Fuel Oil Pump, (9) Shop Exhaust Fan. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:02pm revealed that there were the following Life Safety loads connected to the Critical branch panel BCL2; (9) Exit & Em Light Outpatient, 10(Generator Day Tank). This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:06pm revealed that there were the following Life Safety loads connected to the Equipment system panel 1E2L1; (15) Exit Lights, (22) Fire Bell. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:36pm revealed that there were the following Life Safety loads connected to the critical branch panel 1CL16; (14) Fire Alarm Pad ER. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:36pm revealed that there were the following non-critical loads connected to the critical branch panel 1CL16; (1) AHU #11 DDC Controls. (17) E Ambulance Garage Walk thru Door, (19) ER Door controls by Registration. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:42pm revealed that there were the following Life Safety loads connected to the Critical branch panel 1CL24; (38) Fire Alarm Pad, (39) Shunt trip for MRI, (41) Emergency Hallway lights north end only, (42) Fire Alarm Panel in New Nurse Station. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:48pm revealed that there were the following Life Safety loads connected to the Critical Branch panel 1CL11; (3) CT Shunt Trip, (11) ER Hall Emergency Light. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:48pm revealed that there were the following non-critical loads connected to the critical branch panel 1CL11; (25) Cardiac Surgery Auto Doors, (27) Cardiac Surgery Auto Doors. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:50pm revealed that there were the following Life Safety loads connected to the Critical branch panel 1CL5; (20) Mammo Emer Lights. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:04pm revealed that there were the following non-life safety loads connected to the Life Safety branch panel 1LSL3; (8) Ceiling from Conference Room, (13) Bed Locators, (15) Penthouse AHU#16 DDC Panel, (17) Penthouse AHU #16 Motor Dampers, (19) Penthouse AHU #16 Lights. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:11pm revealed that there was the following non-critical load connected to the critical branch panel 1CL20A; (32) ICU Doors. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 6:13pm revealed that there was the following non-critical load connected to the Critical branch panel 1CL20B; (78) Surgery Double Doors Opener. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:14pm revealed that there was the following critical load connected to the Life Safety branch panel 1LSL2; (4) Dukane Nurse Call Panel. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:17pm revealed that all loads connected to the Critical branch panel 1CL17 are all Equipment system loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:38pm revealed that there were the following non-life safety loads connected to the Life Safety branch panel 2MLSL1; (2) AHU #4 Control, (4) AHU #3 Control, (6) Motor Control Circuit, (8,10) AHU #4 Air Pressure Switch, (9,11) 208V Plug Kitchen West, (16,18) 208V Plug Kitchen West. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:45pm revealed that there were the following non-critical loads connected to the critical branch panel P9CL2; (2) DDC Controls / Door Controls, (6) Neumatic Controls. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 3:09pm revealed that there was the following Life Safety load connected to the equipment system branch panel 2E1L1; (3) Emergency & Exit Lights. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 3:12pm revealed that there were the following non-life safety loads connected to the Life Safety branch panel 2LSL1; (13) First floor plug by Elevator, (18) Room 235 over bed light, (20) Room 235 Bed Plugs, (23) DDC panel AHU #7 & Patient rooms and Doors, (24) TV Amp, and (25) Nurses Conference Room Plugs. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 3:45pm revealed that there was the following Life Safety load connected to the Critical branch panel SMCL1; (6) 1st Floor Exit Lights. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 3:45pm revealed that there were the following non-critical loads connected to the Critical branch panel SMCL1; (2) Condensate Pump S. Mech. Room, (4) Circulation Pump S. Mech. Room, and (16) AHU #6 & 8 DDC Panels. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 3:53pm revealed that there were the following non-life safety loads connected to the Life Safety branch panel 2WLSL1; (8) Lights Room 222, (9) Outlets Room 227, (11) Outlets Room 227, and (16) GFI by Sink. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
K145 East Campus
Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 8:45am revealed that the Life Safety loads for the emergency generator system were connected to the Critical branch panel GCL1 and fed from Critical branch panel 1CL4. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18,2012 at 8:54am revealed that the following life safety load was connected to the equipment system panel MCCE1; (11) Fire Alarm Doors. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 8:58am revealed that there were the following Life Safety loads connected to the Critical branch panel BCL14; (25) Main Fire Alarm and (36) Boiler Rom Exit signs. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 8:58am revealed that there were the following non-critical loads connected to the Critical Branch panel BCL14; (5) 3rd Floor Heat, (9) Temp. Control, (16) Exhaust Fans East Roof, (18) Exhaust Fans East Roof, and (20) Feed water Tank Boilers 1 & 2. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:06am revealed that was the following non-critical load connected to the Critical branch panel BCL13; (17) Boiler #1 Control. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:10am revealed that there were the following non-critical loads connected to the Critical branch panel BCL11; (19,21,23) Sewage Injection Pumps and Controls, (33) Office DDC Controller, (34) Shop South Outlets, (35) BR Office Outlets, (36) Shop North Outlets, (37) Boiler?, (38) Heater Outlet Shop, and (40,42) Air Conditioner. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:11am revealed that all the loads connected to the Critical branch panel BCL5 were equipment system loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:14am revealed that all the loads connected to the Critical branch panel BCL8 were equipment system loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:19am revealed that all the loads connected to the Critical branch panel BCL9 were equipment system loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:32am revealed that all the loads connected to the Critical branch panel BCL6 were equipment system loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:34am revealed that there were the following Life Safety Loads connected to the Critical branch panel BCL2; (2) First Floor W. Hall lights, (3) 3rd Floor Exit Lights, (4) Stairwell Lights, (5) 3rd Floor Hall Lights, (6) Exit Lights, (7) Outside Lights, (8) Ground Floor Exit Lights, (11) 1st Floor Hall Lights, (12) Fire Alarm, (15) 2nd Floor Hall Lights, (19) 1st, 2nd, 3rd, Exit and Doctors Door, (23) 2nd Floor Hall and Stair Lights, (24) emergency Lights, and (31) Boiler room and Stair Lights. Observation on September 18, 2012 at 9:11am revealed that all the loads connected to the Critical branch panel BCL5 were equipment system loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:34am revealed that there were the following non-critical loads connected to the Critical branch panel BCL2; (10) Exhaust Fan #4, (14) Exhaust Fan #3, (16) Exhaust Fan #5, (18) Exhaust Fan #1, (20) Ground Floor Vending Machines, (22) Ground Floor Vending Machines, and (33) Tool Room Outlets. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:43am revealed that there were the following non-critical loads connected to the critical branch panel 1CL5; (2) Exhaust Fan, (4) Home Health Heating Unit, (7) Sump Pump, and (10,12,14) Chapel Air Conditioner. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:50am revealed that there were the following non-critical loads connected to the Critical branch panel 1CL7; (6) Fan-coil Room 143, (8) Fan-coil Lobby, (10) Fan-coil Center, (12) Fan-coil East, and (23,25) Heater 208V. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:55am revealed that there were the following non-critical loads connected to the critical branch panel 1CL3; (1) Walk-in Cooler Fan, (2) Freezer door Heat Strip, and (8) Morg Compressor, dishwasher fan, east corridor lights, northwest wall rec cafe. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:59am revealed that there were the following Life Safety loads connected to the critical branch panel 1CL1; (1) Emergency Lights, and (3) Emergency Lights. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:02and revealed that there were the following non-critical loads connected to the critical branch panel BCL7; (1) Kitchen Ovens, (3) Old Outlet for Vacuum Pump, Surgery, Kitchen, AHU Room, (17) Filters in Air Handler, and (19) Low Pressure Steam Alarm. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:11am revealed that there were the following Life Safety Loads connected to the Critical branch panel 2CH2; (2) Emergency lights Office Area, (6) Emergency Lights South Corridor. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18,2012 at 10:13am revealed that there were the following Life Safety loads connected to the critical branch panel 2CL2; (4) Elevator Lights and (6) Exit Lights 2nd & 3rd Floors. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.

Observation on September 18, 2012 at 10:21am revealed that there was the following Life Safety load connected to the Critical branch panel 2CL3; (7) Life Safety Lights. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:28am revealed that there was the following Life Safety load connected to the critical branch panel 2CH1; (2) Life Safety Psych. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:29am revealed that there were the following non-critical loads connected to the Critical branch panel 2CL1; (6) West Dock Door & Control Masters Control, and (7) Control Masters Service Doors Panel. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:33am revealed that there was the following non-critical load connected to the critical branch panel 2CL7; (5) Mitsubishi Mr. Slim east Side. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:38am revealed that there was a Life Safety load for the Fire Alarm system connected to the Critical branch panel 3CL1. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:44am revealed that there was the following Life Safety load connected to the Critical branch panel 3CL4; (32) Fire Alarm, PE & Drive. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:44am revealed that there were the following non-critical loads connected to the critical branch panel 3CL4; (27) TCV CSI Air Handler, (37,39,41) Air Handler Return Fan TCV AHU, and (38,40,42) Air Handler Supply Fan TCV AHU. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:55am revealed that there was a Life Safety load for the Fire Alarm system that was connected to the Critical Branch panel 4CL1. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:55am revealed that there were the following non-critical loads connected to the critical branch panel 4CL1; (4) Control Masters and (6) Door Locks. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 11:13am revealed that there were the following non-critical loads connected to the critical branch panel P1CL1 for the Elevator and for the Kitchen Exhaust Hood. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 11:18am revealed that Elevator cab lights are connected to the critical branch panel 2CL2 instead of the Life Safety branch as required. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 11:34am revealed that there were the following non-critical loads connected to the Critical branch panel BCL3; (1) Cooling Tower on Roof, (8) DDC Panel Cooling Tower, and (15,17) Communications Room Cove Heater. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.

NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust syst

K-147
Based on observation and interview the facility failed to provide tamper resistant outlets in the Pediatric areas of the hospital and prohibit the use of power strips and extension cords as a substitute for adequate wiring. The facility failed to provide confirm UL listings on power-strips used on medical equipment. These deficient practices have the potential to affect patients in the areas were power strips and extension cords were used. The facility census was 60 patients.

Findings are:
Observations on 9-11-12 between 8:02 am and 10:35 am on 3rd floor patient tower revealed:
1. Medical equipment plugged into a power-strip in C-section Room 2 failed to provide a UL listing.
2. Facility failed to verify UL listing on the power-strip used in the Nursery.
3. Medical equipment plugged into a non-hospital grade power-strip in the Nursery.
4. Refrigerator and milk warmer plugged into a power-strip in the 3rd floor Breast Milk Room.
5. Rolling TV/DVD cart in Patient Room 324 failed to provide hospital grade power- strip.
6. Refrigerator plugged into a power strip in room 3A221.
7. Power-strip used as permanent wiring to charge batteries in room 3A221.
8. Accu-check Pediatric plugged into a non-hospital grade power-strip in room 3A220.
9. Power-strip used as permanent wiring to charge scanners in room 3A220.
10. Computer in the Women ' s/Children ' s waiting room plugged into a non-hospital grade power-strip.
11. Facility failed to provide tamper resistant outlets in the Pediatric Rooms 326-332.
12. Facility failed to provide tamper resistant outlets in the corridor of the Pediatric wing.
Observations on 9-11-12 between 2:27 pm and 3:37 pm on 1st floor OR areas revealed:
13. Extension cord plugged into Slush Machine on the South wall in OR 7.
14. Non-hospital grade power strip used as permanent wiring for a Blanket Warmer.
15. Two non-hospital grad power strips used as permanent wiring for charging battery pac on a cart outside of OR 6.
16. Facility failed to verify the UL listing on numerous power-strips used in the OR area.
17. Refrigerator plugged into a power-strip in the Suture Storage Room.
Observations on 9-11-12 at 3:53 pm on 1st floor revealed:
18. Non-hospital grade power-strip in the Hypobaric room W1116.
Observations on 9-12-12 between 9:22 am and 3:23 pm on 1st floor revealed:
19. Storage of a ladder and three bulletin boards in front of Electrical Panel Boxes CTScan BCXH and ICL2 in the Electrical Room near the ice machine in the ED area

During an interview on at each time of observations, confirmed the findings

NFPA Standard:
Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Sufficient access and working space of 3 feet shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. 1999 NFPA 70 110.26

K-147
Based on observation and staff interview, the facility failed to use electrical wiring in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical fire. Facility census was 69 of 227.

Findings are:
Observation during the facility tour on 9/11/12, from 2:55 pm to 9/12/12, at 9:00 am revealed:
1. Power strips were ganged together near the filing cabinets in the Operating Room Scheduling Office. A coffee maker was also plugged into a power strip. The facility to plug the power strips and the heat producing appliance directly into wall outlets.
2. Power strips were ganged together for the crash cart in the PACU by the South Door. The facility failed to plug the power strips directly into a wall outlet.
3. A power strip tested in accordance with UL 60601-1 failed to be provided for the computers in Exam Rooms 2 and 4 of the West Campus Wound Center.
4. A power strip tested in accordance with UL 60601-1 failed to be provided for medical equipment in the Ablation #1 Room of the West Campus Wound Center.
5. Crockpots were plugged into a power strip in the Radiology Break Room. The heat producing appliances failed to be plugged directly into a wall outlet.
6. A power strip tested in accordance with UL 60601-1 failed to be provided for equipment on each counter in the West Campus Cath Lab 2.
7. A churn pump was plugged into an extension cord in the West Campus Cooling Tower Chemical Area. The facility failed to not use an extension cord in lieu of permanent wiring.
In an interview conducted at the time of observation (9/11/12, from 2:55 pm to 9/12/12, at 9:00 am), Maintenance A acknowledged the use of the electrical equipment.

K147 West MOB
Based on observation and interview the facility failed to identify the type, size and location of the emergency power supply system at the main service disconnect for the building to alert responding personnel that there is an alternate source of power in the building and that shutting off the main service disconnect will not turn off all power in the building in the case of an emergency. This deficient practice has the potential to affect all occupants of the facility. The facility capacity is 227 and the census is 60.
Findings are
Observation on September 18, 2012 at 3:58pm revealed that there was no signage at the main service disconnect for the building to indicate the presence of the emergency power supply system for the building. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.

K-147 North Office Building

Based on Observation and interview the facility failed to maintain the electrical system in accordance with the National Electrical Code by not having feeders and branch circuits clearly identified as to use and purpose and by not providing signage at the main electrical service disconnect to indicate the presence of an emergency power supply system. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 2:07pm revealed that the feeder for the Critical branch panel 1CH1 was not properly identified. It was labeled as coming from a normal panel and not from the emergency system. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 2:08pm revealed that circuits from the normal distribution panel 1NDHP4 were not properly identified as to their use. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 110.22
Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
Observation on September 18, 2012 at 4:08pm revealed that there was no signage at the main service disconnect for the building to indicate the presence of the emergency power supply system for the building. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.

K147 West Bed Tower
Based on Observation and interview the facility failed to maintain the electrical system in accordance with the National Electrical Code by not having feeders and branch circuits clearly identified as to use and purpose and by not having signage at the main service disconnect to indicate the presence of an emergency power supply system. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 17, 2012 at 11:45am revealed that circuit directory for the critical branch panel B1CL1 Sections 1 & 3 were not complete and had circuit descriptions marked by a question mark. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 1:35pm revealed that the feeder breaker for the critical branch panel B2CL2 located in the Critical branch panel B2CL1 Section 2 was not labeled. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 2:08pm revealed that the circuits in the Critical branch panel APCL1 were not clearly marked to identify their use and appropriateness on the Critical branch. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 110.22
Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
Observation on September 18, 2012 at 4:10pm revealed that there was not any signage installed at the main electrical service disconnect to indicate the presence of an emergency power supply system. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.

K147 West Campus
Based on Observation and interview the facility failed to maintain the electrical system in accordance with the National Electrical Code by not having feeders and branch circuits clearly identified as to use and purpose and by not having signage at the main service disconnect to indicate the presence of an emergency power supply system. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 17, 2012 at 3:57pm revealed that the circuit directory for the critical branch panel 1CL23 was incomplete. . This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:30pm revealed that the circuit directory for the equipment system branch panel ODE2L1 was incomplete. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 110.22
Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
Observation on September 18, 2012 at 4:03pm revealed that there was not any signage installed at the main electrical service disconnect to indicate the presence of an emergency power supply system. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.

K147 East Campus
Based on Observation and interview the facility failed to maintain the electrical system in accordance with the National Electrical Code by not having feeders and branch circuits clearly identified as to use and purpose, by not maintaining panels that are dead front, and by not providing signage at the main electrical service disconnect to indicate the presence of an emergency power supply system. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 10:37am revealed that there was no circuit directory for the Critical branch panel 3CL1. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:53am revealed that the circuit directory for the critical branch panel 4CH1 was incomplete.
NFPA 70, 1999ed. 110.22
Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
Observation on September 18, 2012 at 11:40am revealed that the equipment system panel GEL3 was not dead front and had an open breaker slot exposing live buss. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 384-18. Enclosure. Panelboards shall be mounted in cabinets, cutout boxes, or enclosures, designed for the purpose and shall be dead front.
Observation on September 18, 2012 at 8:30am revealed that there was no signage installed at the main electrical service disconnect to indicate the presence of an emergency power source. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.

K-211
Based on observation and interview the facility failed to assure that Alcohol Based Hand Rub (ABHR) dispensers, were installed so that they were not above an electrical ignition source. The facility census was 60 patients.

Findings are:
Observations on 9-11-12 at 3:18 pm and 3:35 pm revealed:
1. An ABHR was installed above an electrical outlet on the south wall in OR 5.
2. An ABHR was installed above an electrical outlet on the east wall in SBD.
Observations on 9-12-12 between 9:40 am and 9:50 am in the ED area revealed:
3. An ABHR was installed approximately 6 inches adjacent to the light switch in Exam Room 1.
4. An ABHR was installed approximately 6 inches adjacent to the light switch in Exam Room 2.
5. An ABHR was installed approximately 6 inches adjacent to the light switch in Exam Room 3.

During an interview on both dates and each time of observations, Maintenance H confirmed the ABHR installed next to or above electrical sources.

Observation during the facility tour on 9/11/12, from 3:08 pm to 9/12/12, at 8:58 am revealed:
1. The alcohol based hand sanitizer in OR 4 failed to not be installed directly over a wall outlet.
2. Rooms W1601 and W1599 failed to have alcohol based hand sanitizers installed at least 12 " away from light switches.
3. The West Campus, 1st Floor Housekeeping Break Room failed to have an alcohol based hand sanitizer installed at least 12 " from the light switch.
In an interview conducted at the time of observations, (9/11/12, from 3:08 pm to 9/12/12, at 8:58 am), Maintenance A acknowledged the findings.

Observation during the survey of the West Campus on between 09-11-12 at 04:16 pm and 09-12-12 at 09:15 am, revealed Alcohol Based Hand Rub dispensers too close to an electrical ignition source in the following rooms.
Door 2592 - inside room
Door 2600 - inside room
Door W1594 - inside room
Door W1532 - Inside room
Observation during the survey of the MOB West on 09-12-12 at 02:27 pm revealed that an Alcohol Based Hand Rub dispenser was above an electrical outlet.
Interview with Maintenance " C " at the time of observance confirmed the deficient placement.

K-18
Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. This practice affected all residents, staff, and visitors of the facility. The facility capacity is 227 and the census was 69.
Findings include:
Observation on 9-11-12 between 8:19 am and 1:37 pm on the 3rd floor Patient Tower revealed:
1. The small inactive leaf on Patient Door 337 failed to provide an automatic flush bolt to provide positive latching.
2. The small inactive leaf on Patient Door 338 failed to provide an automatic flush bolt to provide positive latching.
3. Facility failed to provide a policy for the closing of the Patient doors which had a smaller inactive leaf during a fire emergency.
4. Patient Door 334 held open with a trash can, when removed the door closed.
Observation on 9-11-12 at 11:19 am on the 1st Floor revealed:
5. The temporary construction door leading into the CT Room Niche failed to latch, black tape placed over the strike plate.
Observation on 9-12-12 at 9:12 am on the 1st Floor ED area revealed:
6. The Doctor ' s Office door near Exam 11 failed to engage the door frame.

During an interview on all dates and each time of observations, Maintenance H confirmed the findings.

NFPA Standard:
The minimum clear width for doors in the means of egress from sleeping rooms; diagnostic and treatment areas, such as x-ray, surgery, or physical therapy; and nursery rooms shall be as follows:
(1) Hospitals and nursing homes - 41.5 in. (105 cm)
(2) Psychiatric hospitals and limited care facilities - 32 in. (81 cm)
Exception No. 1:
Doors that are located so as not to be subject to use by any health care occupant shall be not less than 32 in. (81 cm) in clear width.
Exception No. 2:
Doors in exit stair enclosures shall be not less than 32 in. (81 cm) in clear width.
Exception No. 3:
Doors serving newborn nurseries shall be not less than 32 in. (81 cm) in clear width.
Exception No. 4:
Where a pair of doors is provided, not less than one of the doors shall provide not less than a 32-in. (81-cm) clear width opening and a rabbet, bevel, or astragal shall be provided at the meeting edge. The inactive leaf shall have an automatic flush bolt to provide positive latching.
2000 NFPA 101, 18.2.3.5

Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 18.3.6.3.1, 18.3.6.2 and 18.3.6.3

K-22
Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 69 of 227.

Findings are:
Observations during the facility tour on 9/11/12, from 9:09 am to 9:34 am revealed:
1. An exit sign failed to be installed near Room 219 on the 2nd Floor of the Bed Tower to direct occupants east.
2. An exit sign failed to be installed near Room 228 on the 2nd Floor of the Bed Tower so that a sign was visible when facing west.
In an interview conducted at the time of observations (9/11/12, from 9:09 am to 9:34 am), Maintenance D confirmed that exit signs were not visible in these areas.

K-25
Based on observation and interview the facility failed to provide smoke barriers with at least ? hour fire resistance rating constructed in accordance with NFPA 101, 8.3, above smoke doors on the 3rd floor. The facility census was 60 patients

Findings are:
Observation on 9-11-12 at 10:19 am and 10:47 am on the 3rd floor Patient Tower revealed:
1. Unsealed penetration around a 3 inch conduit and two ? inch conduits above ceiling tiles above the double smoke doors 3B550 across from room 306 next to Triage Room.
2. Unsealed penetrations around three 3 inch cable pipes above ceiling tiles above the double smoke doors 3A153 next to room 330.
During an interview on 9-11-12 at both times of observations, Maintenance H confirmed the unsealed penetrations.
NFPA Standard:
Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

K27
Based on observation and interview, the facility failed to provide doors in smoke barriers to create a barrier to resist the passage of smoke on the 3rd floor in the Patient Tower and the 1st floor OR area. This failure would allow smoke to migrate from one smoke compartment to another in the facility. Facility census was 60 patients.

Findings are:
Observation on 9-11-12 at 9:28 am on the 3rd floor Patient Tower revealed:
1. 3A550 double doors had a gap at the meeting edge greater than 1/8 inch.
During an interview on 9-11-12 at 9:28 am, Maintenance H confirmed the gap between the doors.
Observation on 9-11-12 at 2:58 pm on the 1st floor OR area revealed:
2. W1671 double doors had a gap at the meeting edge greater than 1/8 inch.
During an interview on 9-11-12 at 2:58 pm, Maintenance D confirmed the gap between the doors.
Observation through testing during the survey on 09-11-12 at 11:41 am, of the Bed Tower 1st floor revealed that the smoke barrier doors IB-154 did not close entirely to provide a smoke tight fit.
Interview with Maintenance " C " at eh time of observation confirmed the doors did not close properly.

K-29
Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for smoke and fire to spread into the egress corridors. Facility census was 69 of 227.

Findings are:
Observation during the facility tour on 9/11/12, at 11:09 am revealed the facility failed to seal two small holes in the corridor wall above the Bed Tower Soiled Linen 1B-222 door.
In an interview conducted at the time of observation, (9/11/12, at 11:09 am), Maintenance D acknowledged the findings.
Observations on 9-11-12 at 8:12 am and 9:12 am on the 3rd floor Patient Tower revealed:
1. The double doors to a storage area within 3 of 5 LDR rooms equipped with closures failed to close and latch within the door frames.
2. Facility failed to provide a self-closing device on Patient Room 332 door used as a storage room.
Observations on 9-11-12 between 2:16 pm and 4:30 pm on 1st floor revealed:
3. The facility failed to provide latching devices on the fire rated double doors leading to the Ambulance Bay.
4. Unsealed penetrations above the ceiling tiles in the Hypobaric Chamber room, approximately 3 feet south of the door on the east wall around numerous pipes.
5. The facility failed to provide 1-hour fire rated doors to the Hypobaric Chamber room.
6. The south door in the Hypobaric Chamber room provided a turn lock on the closure.
Observations on 9-11-12 between 2:16 pm and 4:30 pm on 1st floor OR area revealed:
7. The Pump room/storage room in the OR area failed to provide latching device.
8. Housekeeping room door W1070 failed to latch, hitting frame.
9. Unsealed hole in door W1071 in the OR area.
10. OR 2 used as a storage room, the double doors failed to provide latching devices.
Observations on 9-12-12 between 9:06 am and 9:18 am on 1st floor revealed:
11. Electrical Room Door W1174 in the ED area failed to latch, hitting frame.
12. The door to the old Trauma Coordinator office which was used as a storage room, failed to provide a self-closing device and latching hardware.
13. The door to the Medication Room in ED which was on a self-closure failed to engage the door frame.
Observations on 9-12-12 at 12:16 pm on 4st floor revealed:
14. 5 gallon plastic water jug holding open the 1 ? hour fire rated door 4A302.2.

During an interview on each day and at each time of observation, Maintenance H and D confirmed the findings.
Observation during the survey on 09-10-12 at 3:30 pm, of the East Campus revealed Voids around electrical conduits in the 4TH floor center electrical room.
Interview with Maintenance " C " at the time of observance confirmed the voids.
Observation during the survey on 09-11-12 at 02:11 pm, of the MOB West revealed the door to the Biohazard would not latch tightly in its frame.
Interview with Maintenance " C " at the time of observation confirmed the door would not latch.

NFPA Standard:
Hypobaric chambers and all ancillary service equipment shall be housed in fire-resistant construction of not less than 1-hour classification that shall be a building either isolated from other buildings or separated from contiguous construction by 1-hour noncombustible (under standard atmospheric conditions) wall construction. 1999 NFPA 99B, 3-1.1

If there are connecting doors through such common walls of contiguity, they shall be at least B label, 1-hour fire doors. All construction and finish materials shall be noncombustible under standard atmospheric conditions. 1999 NFPA 99B, 3-1.1.1

K-33
Based on observation and staff interview, the facility failed to penetrate 2 of 3 of the new Bed Tower stair enclosures with the items only allowed by NFPA 101, 7.1.3.2.1(e). This condition had the potential to allow smoke to enter the exit stairwells. Facility census was 69 of 227.

Findings are:
Observations during the facility tour on 9/11/12, from 8:34 am to 8:37 am revealed:
1. The East Bed Tower Stairwell failed to have utilities such as an elevator sump pump discharge pipe and a condensate pipe separated from the stair enclosure that passed through the enclosure.
2. The Center Bed Tower Stairwell failed to have utilities such as water and steam pipes separated from the stair enclosure that passed through the enclosure.
In an interview conducted at the time of observation, (9/11/12, from 8:34 am to 8:37 am), Maintenance D acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.1.3.2.1(e) Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.

K-38
Based on observation and interview, the facility failed to post the delayed egress signage on the 3rd floor OB stair tower door and failed to provide documentation for the approval of a 30 second delay. This deficient practice would cause confusion and delay egress. The facility census was 60 patients.

Findings are:
Observations on 9-11-12 at 8:38 am revealed the facility failed to post delayed egress signage on the magnetically locked 3rd floor stair tower door 3BO98C. When tested the door released in 30 seconds.

During an interview on 9-11-12 at 8:38 pm, Maintenance H confirmed the lack signage and failed to provide documentation for the approval of 30 second delay in lieu of 15 seconds.
NFPA Standard:
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, provided that the following criteria are met: doors shall unlock upon actuation of an approved, supervised automatic sprinkler system or any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system; the doors shall unlock upon loss of power; an irreversible process shall release the lock within 15 seconds upon application of a force not to exceed 15 pounds nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only; on the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch wide on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. 2000 NFPA 101, 7.2.1.6.1

Based on observation, staff interview and record review, this facility is not providing an all-weather surface from each exit to a public way (an area of safety) or providing a key for every staff member to carry for locked doors within the path of egress, affecting all occupants of the facility. This facility has a capacity of 227 with a census of 69 residents. Findings include:
During the survey of the West Campus on 09-12-12 between 02:00 pm and 03:00 pm, observation revealed the exit discharge passageway did not extend to the public way for the following exits W1228 and W1229.
Interview with Maintenance " E " confirmed the Exit ways did not extend to the public way.
NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

NFPA Standard: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1

K-44
Based on observation and staff interview, the facility failed to maintain two-hour fire barriers of horizontal exits. This condition had the potential to allow smoke and fire to migrate into separate buildings. Facility census was 69 of 227.

Findings are:
Observation during the facility tour on 9/11/12, from 9:33 am to 9:44 am revealed:
1. Two penetrations failed to be sealed on the new side above the Bed Tower W617 Fire Doors.
2. A penetration failed to be sealed on the west side of the Bed Tower 2A-154 Fire Doors.
In an interview conducted at the time of observation, (9/11/12, from 9:33 am to 9:44 am), Maintenance D acknowledged the findings.

K-45
Based on observation and interview the facility failed to maintain the exit discharge lighting so that the failure of one bulb would not leave the path from the facility to the public way in darkness. This deficient practice affects all occupants of the building. This facility has a capacity of 227 and a census of 69 residents.
Findings include:
During the survey of the West Campus on 09-12-12 between 02:00 pm and 03:00 pm, observation and interview revealed the following Exit Discharges to have only one - one bulb lighting fixture or none at all W1234,W1002,W1238,W1188,W1184,W1162,W1229,W1228,W1224 and W1236
Interview with Maintenance " E " at the time of findings confirmed the lack of the required two bulb lighting.
During the survey of the Bed Towers on 09-12-12 between 03:00 pm and 03:30 pm, observation and interview revealed the following Exit Discharges to have only one - one bulb lighting fixture.
1B-553-2 1A-098A-1
Interview with Maintenance " E " at the time of findings confirmed the lack of the required two bulb lighting.

During the survey of the East Campus on 09-10-12 at 02:40 pm, observation and interview revealed the following Exit Discharge to have only one - one bulb lighting fixture.
#2 Stairwell Exit Discharge
Interview with Maintenance " D " at the time of findings confirmed the lack of the required two bulb lighting

K-46
Based on observations and interview the facility failed to verify the operation of the battery operated emergency light in 1 of 2 C-Section Rooms. This deficient practice could affect the patient in the event of a power failure. The facility had a census of 60 patients.

Findings are:
Observations on 9-11-12 at 8:04 am revealed the battery operated emergency light in 1 of 2 C-Section Rooms was blinking a red light five times in sequence. The battery operated emergency light in the other C-Section Room was green.

During an interview on 9-11-12 at 8:04 am, Maintenance G failed to confirm that the emergency light blinking red in 1 of 2 C-Section rooms was operational. And failed to provide documentation of what the blinking light indicated.

During the survey of the West Campus on 09-12-12 between 02:00 pm and 03:00 pm, observation and interview revealed the pathway from Exit W1224 to the Point of Safety was void Emergency Lighting.
Interview at the time of finding with Maintenance " E " confirmed the lack of emergency lighting.
NFPA Standard:
The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101, 7.9.3

K-47
Based on observation and interview, the facility failed to provide exit signs to indicate the continuous path of egress on the 3rd floor of the Patient Tower. This deficient practice affected all patients, staff and visitors that use the OB and Womens/Childrens Wings on the 3rd floor. The facility census was 60 patients.

Findings are:
Observations on 9-11-12 at 8:47 am and 9:00 am, on 3rd floor Patient Tower revealed:
1. While standing in the corridor outside Room 320 looking south, an exit sign could not be seen to indicate the second required exit.
2. While standing in the corridor outside Room 326 looking south, an exit sign could not be seen to indicate the second required exit.

During an interview on 9-11-12 at 8:47 am and 9:00 am, Maintenance H confirmed the second exit sign could not be seen.
Observation during the survey on 09-10-12 at 14:02 pm, of the East Campus revealed the lack of an exit sign directing to the exit at the south end of the Intensive Behavioral Health Unit.
Interview with Maintenance " D " at the time of observation confirmed the lack of the sign.
Observation during the survey on 09-11-12 at 11:15 am, of the Bed Tower 1st floor revealed the lack of an exit sign in the corridor by the ICU room 10 and the lack of a double faced exit sign in the corridor by the ICU room 8.
Interview with Maintenance " C " at the time of observation confirmed the lack of exit signs.

K51
Based on observations and interview the facility failed to provide fire alarm devices with a visual illumination to be located in the operating rooms of the facility. Not providing the visual lighting could cause a fire emergency to go undetected in those rooms of the facility because of the inability to hear the alarm device. The facility had a census of 60 patients.

Findings are:
Observations during the fire alarm testing on 9-12-12 between 10:00 am and 12:30 pm on 3rd Floor Patient Tower and the OR area revealed:
1. Facility failed to provide a visual and audible fire alarm device in the Surgery sleep room.
2. Facility failed to provide visual fire alarm notification devices in the OR ' s of the facility.
3. The fire alarm sound could not be heard within an unoccupied OR.
4. The facility failed to provide audible or visual devices in the Sterile Processing Restroom and Locker Room.

During an interview on 9-12-12 during the fire alarm test, Maintenance H and D confirmed the findings.
NFPA Standard:
Means of egress shall have signs in accordance with Section 7.10. 2000, NFPA, 18.2.10.1
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. 2000, NFPA, 7.10.1.2


Based on observation and staff interview, the facility failed to install the fire alarm system in accordance with NFPA 72. This condition created the potential that the fire alarm would fail to effectively alert occupants. Facility census was 69 of 227.

Findings are:
Observations during the facility tour on 9/11/12, from 8:18 am to 9/12/12, at 10:24 am revealed:
1. A fire alarm strobe failed to be installed within fifteen feet of the Ground Level Bed Tower fire doors LB-551 on the west side of the doors.
2. A fire alarm strobe failed to be installed within fifteen feet of the 2nd Floor Bed Tower fire doors 2B552 on the east side of the doors.
3. A fire alarm strobe failed to be installed within fifteen feet of the 2nd Floor Bed Tower fire doors 2A593 on the east side of the doors.
4. A fire alarm strobe failed to be installed within fifteen feet of the 2nd Floor Bed Tower fire doors 2A154 near Room 227.
5. Fire alarm strobes failed to be synced in the Ground Level Bed Tower Mechanical Room.
6. Fire alarm strobes failed to be synced in the Ground Level Bed Tower Dining Room.
7. A fire alarm notification device failed to be installed in the new West Campus, 1st Floor Hyperbaric Room.
In an interview conducted at the times of observation, (9/11/12, from 8:18 am to 9/12/12, at 10:24 am), Maintenance B acknowledged the findings.
During the survey on 09-12-12 of the West Campus 2nd floor at 04:25 pm, the Hospitalist sleeping room was observed to be void the required Single Station Smoke detection and Audio/Visual notification of the facility Fire Alarm System.
Interview with Maintenance " A " at the time of observation confirmed the lack of smoke detection and Audio/Visual notification.

Actual NFPA Standards:
NFPA 72, 4-4.4.2.2*
Visible notification appliances shall be located not more than 15 ft (4.57 m) from the end of the corridor with a separation not greater than 100 ft (30.4 m) between appliances. If there is an interruption of the concentrated viewing path, such as a fire door, an elevation change, or any other obstruction, the area shall be treated as a separate corridor.

NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.

K-56
Based on observation and interview the facility failed to install automatic sprinkler protection to provide complete coverage for all portions of the building in accordance with NFPA 13 (sprinkler code) in the new enclosed Emergency Department Entry. This deficient practice would allow fire and smoke spread. The facility census was 60 patients.

Findings are:
Observations on 9-11-12 at 11:16 am revealed the facility failed to provide sprinkler protection in the newly constructed enclosed Emergency Department Entry.

During an interview on 9-11-12 at 11:16 am, Maintenance H confirmed the facility failed to provide sprinkler protection.
Observations during the facility tour on 9/11/12 from 7:51 am to 9/12/12, at 4:00 pm revealed:
1. An upright sprinkler head in the Lower Level Bed Tower Electrical Room failed to be installed so that an electrical conduit would not obstruct the head near a junction box at the ceiling labeled B1LH5.
2. Sprinkler heads in the Bed Tower LA17 Basement Server Room failed to be installed so that a water main and conduit would not obstruct the heads.
3. 3 of 3 stairwells in the Bed Tower failed to have sprinkler protection installed at the top and bottom of the stairs.
4. All fire department connections on the Emergency Room Road failed to be labeled as to the areas they served.
5. A sprinkler escutcheon failed to be installed in the West Campus, 1st Floor Wound Center Communications Room.
In an interview conducted at the times of observations, (9/11/12 from 7:51 am to 9/12/12, at 4:00 pm), Maintenance D acknowledged the findings.

Actual NFPA Standards:
NFPA Standard:
Where required by 18.1.61 health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 2000 NFPA 101, 18.3.5
NFPA 13, 5-13.3.2
In noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft.

NFPA 13, 5-1* Basic Requirements.
5-1.1*
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

NFPA 25, 9-7 Fire Department Connections.
9-7.1
Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

K-69
Based on observation and staff interview, the facility failed to provide an approved method to return all wheeled appliances to an approved design location under the range hood suppression system in the Kitchen. This condition had the potential for a fire to start on an appliance and not be suppressed by the suppression system due to the appliance being out of the approved location. Facility census was 69 of 227.

Findings are:
Observation during the facility tour on 9/11/12, at 8:03 am revealed the griddle failed to be centered under the suppression system nozzles during the survey. The facility failed to provide an approved method to have the griddle and all wheeled appliances protected by the suppression system returned to the approved location.
In an interview conducted at the time of observation, (9/11/12, at 8:03 am), Maintenance D acknowledged the findings.

Actual NFPA Standard:
NFPA 96, 12.1.2.3.1 An approved method shall be provided that will ensure that the appliance is returned to an approved design location.

K-72
Based on observation and interview, the facility failed to maintain the means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice affected all patients, visitors and staff that use exit corridor near the ED check-in area. Facility census was 60 patients.

Findings are:
Observations on 9-10-12 and 9-11-12 at various times revealed folding chairs, wheel chairs and movable walls in the corridor near the ED check in which narrowed the corridor width.

During an interview on each day and at various times, Maintenance H confirmed the items in the corridor.

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

K-78
Based on record review and staff interview, the facility failed to maintain humidity levels at 35% or greater at times of operations in 5 of 5 Operating Rooms. This condition increased the potential of the ignition of flammable germicide used during operations. Facility census was 69 of 227.

Findings are:
Record review of operating room humidity logs revealed records were only available up to June of 2012. Humidity levels failed to be maintained at 35% or greater on various dates and times. Records of humidity levels prior to June 2012 were incomplete.
In an interview conducted at the time of record review, (9/12/12, at 2:40 pm), Maintenance D acknowledged the findings.

K-106
Based on Observation and interview the facility failed to provide a Type I Essential Electrical System in the East Campus throughout the facility. A new generator and distribution system had been installed in 2009 that included all three branches of a Type I Essential Electrical System however this system existed only on the fourth floor. The remainder of the facility has only a Type III Essential Electrical System. This deficient practice would affect all residents, staff and visitors of the facility in the event of an emergency. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 8:35am revealed that there was a new emergency distribution system installed in the facility and it was only taken to the remodeled area of the fourth floor. The remaining systems were all just connected to the critical branch of the new system. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.

K-130
Based on observations and documentation review the facility failed to maintain and test the Line Isolation Monitor (LIM) per 1999 NFPA 99. This deficient practice would affect the operation of the LIM during a medical procedure and the patient. Facility census was 60 patients.

Findings are:
Observations on 9-11-12 at 2:47 pm revealed the facility failed to provide LIM or GFCI outlets in functional OR ' s. A LIM was located in the nonfunctional OR 2 which was being used as a storage room.

During an interview on 9-11-12 at 2:27 pm, Maintenance D failed to confirm the testing of the LIM.

Documentation review on 9-17-12 confirmed the facility failed to maintain the LIM on a monthly basis.

NFPA Standard:
1999 NFPA 99, 3-3.3.4.2 Line Isolation Monitor Tests.
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.
Based on Observation and interview the facility failed to provide a safe means of filling or transferring fuel to the Generator fuel supply in the North Medical office in accordance with the requirements of NFPA 37/6.5.4. This deficient practice has the potential to affect all occupants of the facility. The facility capacity is 227 and the census is 60.
Findings Include:
Observation on September 18, 2012 at 1:17pm revealed that there was no overflow line, high level alarm or high-level automatic shutoff to the fuel filling line at generator fuel supply tank. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.

NFPA Standard:
6.5.4 Fuel tanks supplied by pumps shall be provided with all of the following:
(1) An overflow line
(2) A high-level alarm
(3) A high-level automatic shutoff

K-130 West Medical Office Building
Based on Observation and interview the facility failed to have the Level 2 emergency generator installed in accordance with NFPA 110, 2002 edition by not providing emergency lighting in the area of the emergency generator and by not having an emergency generator shut down switch outside the area of the generator. This deficient practice has the potential to affect all occupants of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 1:17pm revealed that there was no emergency lighting in the area of the emergency generator in the mechanical room of the third floor. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 110, 2002ed. 7.3 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
Observation on September 18, 2012 at 1:18pm revealed that the emergency shutdown switch for the emergency generator was located in the same room as the generator and would not allow for safe shutdown of the emergency generator in the case of fire or other emergency involving the generator itself. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 110, 2002ed. 5.6.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

K130 NORTH MEDICAL OFFICE BUILDING
Based on Observation and interview the facility failed to have the Level 1 emergency generator installed in accordance with NFPA 110, 2002 edition by not having the generator installed in a separate room separated by a minimum of two-hour fire-rated construction, by not providing emergency lighting in the area of the emergency generator and by not having an emergency generator shut down switch outside the area of the generator. This deficient practice has the potential to affect all occupants of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 1:32pm revealed that the emergency generator was installed in a room with only a one-hour fire protection rating with just one layer of fire-rated drywall on each side of the metal stud framing and doors with only a one-hour fire rating. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 110, 2002ed. 7.2 The EPS shall be installed in a separate room for Level 1 installations. EPSS equipment shall be permitted to be installed in this room. The room shall have a minimum 2-hour fire rating or be located in an adequate enclosure located outside the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local building codes. No other equipment, including architectural appurtenances, except those that serve this space, shall be permitted in this room.
Observation on September 18, 2012 at 1:36pm revealed that there was no emergency lighting in the area of the emergency generator in the generator room of the third floor. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 110, 2002ed. 7.3 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
Observation on September 18, 2012 at 1:34pm revealed that the emergency shutdown switch for the emergency generator was located in the same room as the generator and would not allow for safe shutdown of the emergency generator in the case of fire or other emergency involving the generator itself. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 110, 2002ed. 5.6.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

K130 WEST CAMPUS (EXISTING)
Based on observation and interview the facility failed to maintain the line isolation panels in the operating rooms by not testing them on a monthly basis. This deficient practice has the potential to affect all patients and staff in the operating rooms by not being able to detect dangerous electrical levels. The facility capacity is 227 and the census is 60.
Findings are:
Observations on September 18, 2012 between 2:30pm and 3:00pm revealed that there were line isolation panels in 4 of the 6 current operating rooms and that the signal devices on all panels had been silenced so as not to alert staff in the event of abnormal conditions. When asked about the panels and monthly testing I was advised that they were not testing the panels and a couple panels has the silence switch broken so as to be not operable. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 99, 199ed. 3-3.3.4.2 Line Isolation Monitor Tests. The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch.

K130 EAST CAMPUS (EXISTING)
Based on Observation and interview the facility failed to have the Level 1 emergency generator installed in accordance with NFPA 110, 2002 by not providing emergency lighting in the area of the emergency generator and by not having an emergency generator shut down switch outside the area of the generator. This deficient practice has the potential to affect all occupants of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 8:32am revealed that there was no emergency lighting installed in the generator enclosure. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 110, 2002ed. 7.3 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

K-145 NORTH MEDICAL OFFICE BUILDING
Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 1:44pm revealed that there were the following non-Life Safety loads connected to the Life Safety branch panel PLSPL; (11) Door Holder 2100, AHU lights and AHU Humidifiers. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 1:54pm revealed that there were the following non-critical loads connected to the Critical branch panel 1CL1; (46) VAV Controls, (48) VAV Controls, (50) Auto Door, (52) AC-1. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
K-145 WEST BED TOWERS (NEW)
Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 17, 2012 at 11:00am revealed that the Critical branch panel ABCL1 contained the following non-critical loads; (1) ELEV PIT LTS S-1, S-2, (2) ELEV PIT LTS P-1, P-2, (3) ELEV PIT REC S-1, S-2, (4) ELEV PIT REC P-1, P-2, (5) ELEV PIT SUMP PUMP S-1, S-2, (6) ELEV PIT SUMP PUMP P-1, P-2, (7) ELEV PIT LTS P-3, (9) ELEV PIT REC P-3, (11) ELEV PIT SUMP PUMP P-3. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 11:12am revealed that there were the following equipment system loads connected to the Life Safety branch panel BBLL; (10) Pneumatic Tube Sorters, (11) Control Panels Pump and Chiller Rooms, (12) Pneumatic Tube Air pump. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 11:40am revealed that there were the following non-life safety loads connected to the Life Safety branch panel B1LL; (13) Well Rec. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 2:06pm revealed that there were the following Life Safety loads connected to the Critical branch panel APCL1; (18) Shunt P1 & P2 Elevator. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.

K145 West Campus
Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 17, 2012 at 2:34pm revealed that all the loads connected to the Critical branch panel BCL1 were not critical loads but were all equipment loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:02pm revealed that there were the following non-critical loads connected to the Critical branch panel BCL2; (1) NE Shop Outlet, (3) Main DDC Plugs in Maint. Computer Room, (5) Chiller Control DDC Panel, (7) Fuel Oil Shed, (8) Boiler Fuel Pump, (12) Simplex Fuel Monitor in Office, (13) MOB North Boiler Fuel Oil Pump, (9) Shop Exhaust Fan. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:02pm revealed that there were the following Life Safety loads connected to the Critical branch panel BCL2; (9) Exit & Em Light Outpatient, 10(Generator Day Tank). This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:06pm revealed that there were the following Life Safety loads connected to the Equipment system panel 1E2L1; (15) Exit Lights, (22) Fire Bell. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:36pm revealed that there were the following Life Safety loads connected to the critical branch panel 1CL16; (14) Fire Alarm Pad ER. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:36pm revealed that there were the following non-critical loads connected to the critical branch panel 1CL16; (1) AHU #11 DDC Controls. (17) E Ambulance Garage Walk thru Door, (19) ER Door controls by Registration. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:42pm revealed that there were the following Life Safety loads connected to the Critical branch panel 1CL24; (38) Fire Alarm Pad, (39) Shunt trip for MRI, (41) Emergency Hallway lights north end only, (42) Fire Alarm Panel in New Nurse Station. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:48pm revealed that there were the following Life Safety loads connected to the Critical Branch panel 1CL11; (3) CT Shunt Trip, (11) ER Hall Emergency Light. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:48pm revealed that there were the following non-critical loads connected to the critical branch panel 1CL11; (25) Cardiac Surgery Auto Doors, (27) Cardiac Surgery Auto Doors. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 3:50pm revealed that there were the following Life Safety loads connected to the Critical branch panel 1CL5; (20) Mammo Emer Lights. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:04pm revealed that there were the following non-life safety loads connected to the Life Safety branch panel 1LSL3; (8) Ceiling from Conference Room, (13) Bed Locators, (15) Penthouse AHU#16 DDC Panel, (17) Penthouse AHU #16 Motor Dampers, (19) Penthouse AHU #16 Lights. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:11pm revealed that there was the following non-critical load connected to the critical branch panel 1CL20A; (32) ICU Doors. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 6:13pm revealed that there was the following non-critical load connected to the Critical branch panel 1CL20B; (78) Surgery Double Doors Opener. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:14pm revealed that there was the following critical load connected to the Life Safety branch panel 1LSL2; (4) Dukane Nurse Call Panel. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:17pm revealed that all loads connected to the Critical branch panel 1CL17 are all Equipment system loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:38pm revealed that there were the following non-life safety loads connected to the Life Safety branch panel 2MLSL1; (2) AHU #4 Control, (4) AHU #3 Control, (6) Motor Control Circuit, (8,10) AHU #4 Air Pressure Switch, (9,11) 208V Plug Kitchen West, (16,18) 208V Plug Kitchen West. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:45pm revealed that there were the following non-critical loads connected to the critical branch panel P9CL2; (2) DDC Controls / Door Controls, (6) Neumatic Controls. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 3:09pm revealed that there was the following Life Safety load connected to the equipment system branch panel 2E1L1; (3) Emergency & Exit Lights. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 3:12pm revealed that there were the following non-life safety loads connected to the Life Safety branch panel 2LSL1; (13) First floor plug by Elevator, (18) Room 235 over bed light, (20) Room 235 Bed Plugs, (23) DDC panel AHU #7 & Patient rooms and Doors, (24) TV Amp, and (25) Nurses Conference Room Plugs. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 3:45pm revealed that there was the following Life Safety load connected to the Critical branch panel SMCL1; (6) 1st Floor Exit Lights. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 3:45pm revealed that there were the following non-critical loads connected to the Critical branch panel SMCL1; (2) Condensate Pump S. Mech. Room, (4) Circulation Pump S. Mech. Room, and (16) AHU #6 & 8 DDC Panels. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 3:53pm revealed that there were the following non-life safety loads connected to the Life Safety branch panel 2WLSL1; (8) Lights Room 222, (9) Outlets Room 227, (11) Outlets Room 227, and (16) GFI by Sink. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
K145 East Campus
Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 8:45am revealed that the Life Safety loads for the emergency generator system were connected to the Critical branch panel GCL1 and fed from Critical branch panel 1CL4. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18,2012 at 8:54am revealed that the following life safety load was connected to the equipment system panel MCCE1; (11) Fire Alarm Doors. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 8:58am revealed that there were the following Life Safety loads connected to the Critical branch panel BCL14; (25) Main Fire Alarm and (36) Boiler Rom Exit signs. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 8:58am revealed that there were the following non-critical loads connected to the Critical Branch panel BCL14; (5) 3rd Floor Heat, (9) Temp. Control, (16) Exhaust Fans East Roof, (18) Exhaust Fans East Roof, and (20) Feed water Tank Boilers 1 & 2. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:06am revealed that was the following non-critical load connected to the Critical branch panel BCL13; (17) Boiler #1 Control. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:10am revealed that there were the following non-critical loads connected to the Critical branch panel BCL11; (19,21,23) Sewage Injection Pumps and Controls, (33) Office DDC Controller, (34) Shop South Outlets, (35) BR Office Outlets, (36) Shop North Outlets, (37) Boiler?, (38) Heater Outlet Shop, and (40,42) Air Conditioner. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:11am revealed that all the loads connected to the Critical branch panel BCL5 were equipment system loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:14am revealed that all the loads connected to the Critical branch panel BCL8 were equipment system loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:19am revealed that all the loads connected to the Critical branch panel BCL9 were equipment system loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:32am revealed that all the loads connected to the Critical branch panel BCL6 were equipment system loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:34am revealed that there were the following Life Safety Loads connected to the Critical branch panel BCL2; (2) First Floor W. Hall lights, (3) 3rd Floor Exit Lights, (4) Stairwell Lights, (5) 3rd Floor Hall Lights, (6) Exit Lights, (7) Outside Lights, (8) Ground Floor Exit Lights, (11) 1st Floor Hall Lights, (12) Fire Alarm, (15) 2nd Floor Hall Lights, (19) 1st, 2nd, 3rd, Exit and Doctors Door, (23) 2nd Floor Hall and Stair Lights, (24) emergency Lights, and (31) Boiler room and Stair Lights. Observation on September 18, 2012 at 9:11am revealed that all the loads connected to the Critical branch panel BCL5 were equipment system loads. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:34am revealed that there were the following non-critical loads connected to the Critical branch panel BCL2; (10) Exhaust Fan #4, (14) Exhaust Fan #3, (16) Exhaust Fan #5, (18) Exhaust Fan #1, (20) Ground Floor Vending Machines, (22) Ground Floor Vending Machines, and (33) Tool Room Outlets. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:43am revealed that there were the following non-critical loads connected to the critical branch panel 1CL5; (2) Exhaust Fan, (4) Home Health Heating Unit, (7) Sump Pump, and (10,12,14) Chapel Air Conditioner. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:50am revealed that there were the following non-critical loads connected to the Critical branch panel 1CL7; (6) Fan-coil Room 143, (8) Fan-coil Lobby, (10) Fan-coil Center, (12) Fan-coil East, and (23,25) Heater 208V. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:55am revealed that there were the following non-critical loads connected to the critical branch panel 1CL3; (1) Walk-in Cooler Fan, (2) Freezer door Heat Strip, and (8) Morg Compressor, dishwasher fan, east corridor lights, northwest wall rec cafe. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 9:59am revealed that there were the following Life Safety loads connected to the critical branch panel 1CL1; (1) Emergency Lights, and (3) Emergency Lights. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:02and revealed that there were the following non-critical loads connected to the critical branch panel BCL7; (1) Kitchen Ovens, (3) Old Outlet for Vacuum Pump, Surgery, Kitchen, AHU Room, (17) Filters in Air Handler, and (19) Low Pressure Steam Alarm. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:11am revealed that there were the following Life Safety Loads connected to the Critical branch panel 2CH2; (2) Emergency lights Office Area, (6) Emergency Lights South Corridor. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18,2012 at 10:13am revealed that there were the following Life Safety loads connected to the critical branch panel 2CL2; (4) Elevator Lights and (6) Exit Lights 2nd & 3rd Floors. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.

Observation on September 18, 2012 at 10:21am revealed that there was the following Life Safety load connected to the Critical branch panel 2CL3; (7) Life Safety Lights. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:28am revealed that there was the following Life Safety load connected to the critical branch panel 2CH1; (2) Life Safety Psych. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:29am revealed that there were the following non-critical loads connected to the Critical branch panel 2CL1; (6) West Dock Door & Control Masters Control, and (7) Control Masters Service Doors Panel. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:33am revealed that there was the following non-critical load connected to the critical branch panel 2CL7; (5) Mitsubishi Mr. Slim east Side. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:38am revealed that there was a Life Safety load for the Fire Alarm system connected to the Critical branch panel 3CL1. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:44am revealed that there was the following Life Safety load connected to the Critical branch panel 3CL4; (32) Fire Alarm, PE & Drive. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:44am revealed that there were the following non-critical loads connected to the critical branch panel 3CL4; (27) TCV CSI Air Handler, (37,39,41) Air Handler Return Fan TCV AHU, and (38,40,42) Air Handler Supply Fan TCV AHU. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:55am revealed that there was a Life Safety load for the Fire Alarm system that was connected to the Critical Branch panel 4CL1. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:55am revealed that there were the following non-critical loads connected to the critical branch panel 4CL1; (4) Control Masters and (6) Door Locks. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 11:13am revealed that there were the following non-critical loads connected to the critical branch panel P1CL1 for the Elevator and for the Kitchen Exhaust Hood. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 11:18am revealed that Elevator cab lights are connected to the critical branch panel 2CL2 instead of the Life Safety branch as required. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 11:34am revealed that there were the following non-critical loads connected to the Critical branch panel BCL3; (1) Cooling Tower on Roof, (8) DDC Panel Cooling Tower, and (15,17) Communications Room Cove Heater. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.

NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust syst

K-147
Based on observation and interview the facility failed to provide tamper resistant outlets in the Pediatric areas of the hospital and prohibit the use of power strips and extension cords as a substitute for adequate wiring. The facility failed to provide confirm UL listings on power-strips used on medical equipment. These deficient practices have the potential to affect patients in the areas were power strips and extension cords were used. The facility census was 60 patients.

Findings are:
Observations on 9-11-12 between 8:02 am and 10:35 am on 3rd floor patient tower revealed:
1. Medical equipment plugged into a power-strip in C-section Room 2 failed to provide a UL listing.
2. Facility failed to verify UL listing on the power-strip used in the Nursery.
3. Medical equipment plugged into a non-hospital grade power-strip in the Nursery.
4. Refrigerator and milk warmer plugged into a power-strip in the 3rd floor Breast Milk Room.
5. Rolling TV/DVD cart in Patient Room 324 failed to provide hospital grade power- strip.
6. Refrigerator plugged into a power strip in room 3A221.
7. Power-strip used as permanent wiring to charge batteries in room 3A221.
8. Accu-check Pediatric plugged into a non-hospital grade power-strip in room 3A220.
9. Power-strip used as permanent wiring to charge scanners in room 3A220.
10. Computer in the Women ' s/Children ' s waiting room plugged into a non-hospital grade power-strip.
11. Facility failed to provide tamper resistant outlets in the Pediatric Rooms 326-332.
12. Facility failed to provide tamper resistant outlets in the corridor of the Pediatric wing.
Observations on 9-11-12 between 2:27 pm and 3:37 pm on 1st floor OR areas revealed:
13. Extension cord plugged into Slush Machine on the South wall in OR 7.
14. Non-hospital grade power strip used as permanent wiring for a Blanket Warmer.
15. Two non-hospital grad power strips used as permanent wiring for charging battery pac on a cart outside of OR 6.
16. Facility failed to verify the UL listing on numerous power-strips used in the OR area.
17. Refrigerator plugged into a power-strip in the Suture Storage Room.
Observations on 9-11-12 at 3:53 pm on 1st floor revealed:
18. Non-hospital grade power-strip in the Hypobaric room W1116.
Observations on 9-12-12 between 9:22 am and 3:23 pm on 1st floor revealed:
19. Storage of a ladder and three bulletin boards in front of Electrical Panel Boxes CTScan BCXH and ICL2 in the Electrical Room near the ice machine in the ED area

During an interview on at each time of observations, confirmed the findings

NFPA Standard:
Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Sufficient access and working space of 3 feet shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. 1999 NFPA 70 110.26

K-147
Based on observation and staff interview, the facility failed to use electrical wiring in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical fire. Facility census was 69 of 227.

Findings are:
Observation during the facility tour on 9/11/12, from 2:55 pm to 9/12/12, at 9:00 am revealed:
1. Power strips were ganged together near the filing cabinets in the Operating Room Scheduling Office. A coffee maker was also plugged into a power strip. The facility to plug the power strips and the heat producing appliance directly into wall outlets.
2. Power strips were ganged together for the crash cart in the PACU by the South Door. The facility failed to plug the power strips directly into a wall outlet.
3. A power strip tested in accordance with UL 60601-1 failed to be provided for the computers in Exam Rooms 2 and 4 of the West Campus Wound Center.
4. A power strip tested in accordance with UL 60601-1 failed to be provided for medical equipment in the Ablation #1 Room of the West Campus Wound Center.
5. Crockpots were plugged into a power strip in the Radiology Break Room. The heat producing appliances failed to be plugged directly into a wall outlet.
6. A power strip tested in accordance with UL 60601-1 failed to be provided for equipment on each counter in the West Campus Cath Lab 2.
7. A churn pump was plugged into an extension cord in the West Campus Cooling Tower Chemical Area. The facility failed to not use an extension cord in lieu of permanent wiring.
In an interview conducted at the time of observation (9/11/12, from 2:55 pm to 9/12/12, at 9:00 am), Maintenance A acknowledged the use of the electrical equipment.

K147 West MOB
Based on observation and interview the facility failed to identify the type, size and location of the emergency power supply system at the main service disconnect for the building to alert responding personnel that there is an alternate source of power in the building and that shutting off the main service disconnect will not turn off all power in the building in the case of an emergency. This deficient practice has the potential to affect all occupants of the facility. The facility capacity is 227 and the census is 60.
Findings are
Observation on September 18, 2012 at 3:58pm revealed that there was no signage at the main service disconnect for the building to indicate the presence of the emergency power supply system for the building. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.

K-147 North Office Building

Based on Observation and interview the facility failed to maintain the electrical system in accordance with the National Electrical Code by not having feeders and branch circuits clearly identified as to use and purpose and by not providing signage at the main electrical service disconnect to indicate the presence of an emergency power supply system. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 2:07pm revealed that the feeder for the Critical branch panel 1CH1 was not properly identified. It was labeled as coming from a normal panel and not from the emergency system. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 2:08pm revealed that circuits from the normal distribution panel 1NDHP4 were not properly identified as to their use. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 110.22
Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
Observation on September 18, 2012 at 4:08pm revealed that there was no signage at the main service disconnect for the building to indicate the presence of the emergency power supply system for the building. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.

K147 West Bed Tower
Based on Observation and interview the facility failed to maintain the electrical system in accordance with the National Electrical Code by not having feeders and branch circuits clearly identified as to use and purpose and by not having signage at the main service disconnect to indicate the presence of an emergency power supply system. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 17, 2012 at 11:45am revealed that circuit directory for the critical branch panel B1CL1 Sections 1 & 3 were not complete and had circuit descriptions marked by a question mark. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 1:35pm revealed that the feeder breaker for the critical branch panel B2CL2 located in the Critical branch panel B2CL1 Section 2 was not labeled. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 2:08pm revealed that the circuits in the Critical branch panel APCL1 were not clearly marked to identify their use and appropriateness on the Critical branch. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 110.22
Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
Observation on September 18, 2012 at 4:10pm revealed that there was not any signage installed at the main electrical service disconnect to indicate the presence of an emergency power supply system. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.

K147 West Campus
Based on Observation and interview the facility failed to maintain the electrical system in accordance with the National Electrical Code by not having feeders and branch circuits clearly identified as to use and purpose and by not having signage at the main service disconnect to indicate the presence of an emergency power supply system. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 17, 2012 at 3:57pm revealed that the circuit directory for the critical branch panel 1CL23 was incomplete. . This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 17, 2012 at 4:30pm revealed that the circuit directory for the equipment system branch panel ODE2L1 was incomplete. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 110.22
Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
Observation on September 18, 2012 at 4:03pm revealed that there was not any signage installed at the main electrical service disconnect to indicate the presence of an emergency power supply system. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.

K147 East Campus
Based on Observation and interview the facility failed to maintain the electrical system in accordance with the National Electrical Code by not having feeders and branch circuits clearly identified as to use and purpose, by not maintaining panels that are dead front, and by not providing signage at the main electrical service disconnect to indicate the presence of an emergency power supply system. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 227 and the census is 60.
Findings are:
Observation on September 18, 2012 at 10:37am revealed that there was no circuit directory for the Critical branch panel 3CL1. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
Observation on September 18, 2012 at 10:53am revealed that the circuit directory for the critical branch panel 4CH1 was incomplete.
NFPA 70, 1999ed. 110.22
Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
Observation on September 18, 2012 at 11:40am revealed that the equipment system panel GEL3 was not dead front and had an open breaker slot exposing live buss. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 384-18. Enclosure. Panelboards shall be mounted in cabinets, cutout boxes, or enclosures, designed for the purpose and shall be dead front.
Observation on September 18, 2012 at 8:30am revealed that there was no signage installed at the main electrical service disconnect to indicate the presence of an emergency power source. This observation was confirmed in an interview with Maintenance B and Maintenance D at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.