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Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. While accompanied by the DFM, the surveyor observed unsealed pipe or other penetrations and incomplete sections of walls in hazardous areas within the 2011 Vertical Expansion, as prohibited by 18.3.2.1 and 8.2.4.2.4.2. Locations observed include:
1. On August 24, 2015 at 1:11 PM: Third Floor ICU Clean Utility Room, unsealed pipe penetrations.

2. On August 24, 2015 at 1:17 PM: Third Floor ICU Soiled Utility Room, unsealed pipe penetrations and sections of shaft wall assembly that lack drywall tape.

B. On August 24, 2015 at 3:05 PM, while accompanied by the DFM, the surveyor observed the door to the Third Floor Surgical Department Clean Utility Room did not close to latch as required by 18.3.2.1 and 8.2.3.2.3.2.

Based on observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

On August 25, 2015 at 10:05 AM, while accompanied by the DFM, the surveyor observed the Ground Floor door to Exit Stair 1 is missing a label, which indicates it carries a minimum 1-1/2 hour fire resistance rating, as required by 8.2.3.2.3.1(1).

Based on observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. On August 24, 2015 at 2:53 PM, while accompanied by the DFM, the surveyor observed the pair of cross-corridor doors, from the Third Floor Corridor adjacent to the ICU to the Corridor within the Mother/Baby LDR Unit, which are a required egress path toward the east, are secured against passage as prohibited by 19.2.2.2.4.

B. The following conditions were observed at the Third Floor door to Exit Stair 3, which was observed to be equipped with a delayed egress locking mechanism:

1. On August 24, 2015 at 2:36 PM, while accompanied by the DFM, the surveyor observed the door lacks a sign which reads "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS" required by 7.2.1.6.1(d).
2. On August 25, 2015 at 12:50 PM, while accompanied by the DFM during a test of the building fire alarm, the surveyor observed that the door does not release upon activation of the building fire alarm system in accordance with 7.2.1.6.1(a). The door was tested by activating both a fire alarm manual pull station and an inspector's test valve as part of the building's automatic sprinkler system.

Based on observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

On August 25, 2015 at 8:55 AM, the exterior egress path from the Corridor serving the Pool Equipment Room was observed to not be complete to a public way, as required by 7.7.1, because there is no walk from the end of the steps to a parking lot or road.

Based on document review, not all emergency lighting is properly installed and maintained. These deficiencies could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

A. On August 25, 2015 at 8:50 AM, while accompanied by the DFM, the surveyor observed that all exterior exit doors lack battery-powered emergency lighting required by 7.9.1.1. This condition was observed to exist at:
1. The exterior door from the Gym.
2. The exterior door from the Corridor serving the Pool Equipment Room.

3. The exterior door from the Exit Stair serving the Second Floor of the Center for Physical Rehabilitation and Activity.

B. On August 25, 2015 at 9:00 AM, while accompanied by the DFM, the surveyor determined that battery-powered emergency lights are not tested for a period of 30 seconds at least once every 30 days as required by 7.9.3. This was confirmed by the DFM at that time.
C. On August 25, 2015 at 9:00 AM, while accompanied by the DFM, the surveyor determined that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3. This was confirmed by the DFM at that time.

Based on document review, not all emergency lighting is properly installed and maintained. These deficiencies could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

On August 25, 2015 at 8:41 AM, while accompanied by the DFM, the surveyor observed all exterior exit doors lack battery-powered emergency lighting required by 7.9.1.1. This condition was observed to exist at:
A. The northwest (main) Entry Door.
B. The east Exit Door (from the Break Room).

Based on staff interview, not all emergency lighting is properly installed and maintained. These deficiencies could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

On August 25, 2015 at 12:30 PM, the MS confirmed all exterior exit doors from the hospital lack battery-powered emergency lighting required by 7.9.1.1.

Based on observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

On August 25, 2015, while accompanied by the DFM, the surveyor observed exit signs which direct building occupants into designated suites as prohibited by 19.2.5.9 and 7.10.1.1. Locations observed include:
A. 1:52 PM: An exit sign was observed which directs occupants of the Third Floor Caesarian Section Unit into the ICU Suite.

B. 3:13 PM: An exit sign was observed which directs occupants from the Second Floor Surgery Department into the Same Day Surgery Suite.

Based on observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are properly installed and maintained. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

On August 24, 2015, while accompanied by the DFM, the surveyor observed rooms or spaces which lack sprinkler heads required by NFPA 13 1999 5-1.1(1). Locations observed include (both Fourth Floor Vertical Expansion):

A. 12:57 PM: Electrical Closet.

B. 12:58 PM: Data Cable Closet adjacent to IDF Room.

Based on staff interview, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

On August 25, 2015, at 9:43 AM, during an interview held in the First Floor Conference Room, the DPS stated that gurneys for surgical cases are typically stored during those cases in the corridors outside of each operating room, in the Second Floor Surgical Department, and thus obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1.

Based on observations made during the survey walk through the surveyor found that the emergency electrical installation did not meet all of the requirements of the applicable codes. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

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

A. On August 24, 2015 at 1:20 PM, while accompanied by the MS, the surveyor observed that Critical Panel 3C, located in the Corridor near the Nurse's Station, is serving a fire alarm NAC panel which is not in compliance with the 1999 edition of NFPA-70, Section 517-32.

B. On August 24, 2015 at 1:45 PM, while accompanied by the MS, the surveyor observed that Critical Panel 1C, located in the First Floor Corridor near the Nurse's Station, is serving a fire alarm panel which is not in compliance with the 1999 edition of NFPA-70, Section 517-32.

Based on observation during the survey walk through the surveyor found that the elevator lighting and control installation did not meet all requirements of the applicable codes. This could affect any occupant of the elevator during an outage of the normal power system.


Findings include:

On August 24, 2015 at 11:00 AM, while accompanied by the MS, the surveyor observed the elevator cab lights in Elevators 7 and 8 are not fed from the Life Safety branch of emergency power in accordance with NFPA-70, Section 517-32, and the elevators are not equipped with cab lighting disconnects in the Elevator Equipment Rooms in accordance with NFPA-70, Section 620-53.

Based on observations made during the survey walk through the surveyor found that the elevators did not meet all of the requirements of ANSI/ASME A17.3. This could affect any occupants of the facility using the elevator if proper safety equipment is not installed on each elevator.

Findings include:

1. On August 24, 2015 at 11:00 AM, while accompanied by the MS, the surveyor observed the Elevator Machine Room for elevator 7 and 8 does not have a heat detector within 2 feet of each sprinkler head, tied to a shunt trip, as required by NFPA-72, Section 3-9.4, and ASME A17.1, Section 102.2(c)(3).

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. While accompanied by the DFM, the surveyor observed unsealed pipe or other penetrations and incomplete sections of walls in hazardous areas within the 2011 Vertical Expansion, as prohibited by 18.3.2.1 and 8.2.4.2.4.2. Locations observed include:
1. On August 24, 2015 at 1:11 PM: Third Floor ICU Clean Utility Room, unsealed pipe penetrations.

2. On August 24, 2015 at 1:17 PM: Third Floor ICU Soiled Utility Room, unsealed pipe penetrations and sections of shaft wall assembly that lack drywall tape.

B. On August 24, 2015 at 3:05 PM, while accompanied by the DFM, the surveyor observed the door to the Third Floor Surgical Department Clean Utility Room did not close to latch as required by 18.3.2.1 and 8.2.3.2.3.2.

Based on observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

On August 25, 2015 at 10:05 AM, while accompanied by the DFM, the surveyor observed the Ground Floor door to Exit Stair 1 is missing a label, which indicates it carries a minimum 1-1/2 hour fire resistance rating, as required by 8.2.3.2.3.1(1).

Based on observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. On August 24, 2015 at 2:53 PM, while accompanied by the DFM, the surveyor observed the pair of cross-corridor doors, from the Third Floor Corridor adjacent to the ICU to the Corridor within the Mother/Baby LDR Unit, which are a required egress path toward the east, are secured against passage as prohibited by 19.2.2.2.4.

B. The following conditions were observed at the Third Floor door to Exit Stair 3, which was observed to be equipped with a delayed egress locking mechanism:

1. On August 24, 2015 at 2:36 PM, while accompanied by the DFM, the surveyor observed the door lacks a sign which reads "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS" required by 7.2.1.6.1(d).
2. On August 25, 2015 at 12:50 PM, while accompanied by the DFM during a test of the building fire alarm, the surveyor observed that the door does not release upon activation of the building fire alarm system in accordance with 7.2.1.6.1(a). The door was tested by activating both a fire alarm manual pull station and an inspector's test valve as part of the building's automatic sprinkler system.

Based on observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

On August 25, 2015 at 8:55 AM, the exterior egress path from the Corridor serving the Pool Equipment Room was observed to not be complete to a public way, as required by 7.7.1, because there is no walk from the end of the steps to a parking lot or road.

Based on document review, not all emergency lighting is properly installed and maintained. These deficiencies could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

A. On August 25, 2015 at 8:50 AM, while accompanied by the DFM, the surveyor observed that all exterior exit doors lack battery-powered emergency lighting required by 7.9.1.1. This condition was observed to exist at:
1. The exterior door from the Gym.
2. The exterior door from the Corridor serving the Pool Equipment Room.

3. The exterior door from the Exit Stair serving the Second Floor of the Center for Physical Rehabilitation and Activity.

B. On August 25, 2015 at 9:00 AM, while accompanied by the DFM, the surveyor determined that battery-powered emergency lights are not tested for a period of 30 seconds at least once every 30 days as required by 7.9.3. This was confirmed by the DFM at that time.
C. On August 25, 2015 at 9:00 AM, while accompanied by the DFM, the surveyor determined that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3. This was confirmed by the DFM at that time.

Based on document review, not all emergency lighting is properly installed and maintained. These deficiencies could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

On August 25, 2015 at 8:41 AM, while accompanied by the DFM, the surveyor observed all exterior exit doors lack battery-powered emergency lighting required by 7.9.1.1. This condition was observed to exist at:
A. The northwest (main) Entry Door.
B. The east Exit Door (from the Break Room).

Based on staff interview, not all emergency lighting is properly installed and maintained. These deficiencies could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

On August 25, 2015 at 12:30 PM, the MS confirmed all exterior exit doors from the hospital lack battery-powered emergency lighting required by 7.9.1.1.

Based on observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

On August 25, 2015, while accompanied by the DFM, the surveyor observed exit signs which direct building occupants into designated suites as prohibited by 19.2.5.9 and 7.10.1.1. Locations observed include:
A. 1:52 PM: An exit sign was observed which directs occupants of the Third Floor Caesarian Section Unit into the ICU Suite.

B. 3:13 PM: An exit sign was observed which directs occupants from the Second Floor Surgery Department into the Same Day Surgery Suite.

Based on observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are properly installed and maintained. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

On August 24, 2015, while accompanied by the DFM, the surveyor observed rooms or spaces which lack sprinkler heads required by NFPA 13 1999 5-1.1(1). Locations observed include (both Fourth Floor Vertical Expansion):

A. 12:57 PM: Electrical Closet.

B. 12:58 PM: Data Cable Closet adjacent to IDF Room.

Based on staff interview, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

On August 25, 2015, at 9:43 AM, during an interview held in the First Floor Conference Room, the DPS stated that gurneys for surgical cases are typically stored during those cases in the corridors outside of each operating room, in the Second Floor Surgical Department, and thus obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1.

Based on observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on observations made during the survey walk through the surveyor found that the emergency electrical installation did not meet all of the requirements of the applicable codes. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

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

A. On August 24, 2015 at 1:20 PM, while accompanied by the MS, the surveyor observed that Critical Panel 3C, located in the Corridor near the Nurse's Station, is serving a fire alarm NAC panel which is not in compliance with the 1999 edition of NFPA-70, Section 517-32.

B. On August 24, 2015 at 1:45 PM, while accompanied by the MS, the surveyor observed that Critical Panel 1C, located in the First Floor Corridor near the Nurse's Station, is serving a fire alarm panel which is not in compliance with the 1999 edition of NFPA-70, Section 517-32.

Based on observation during the survey walk through the surveyor found that the elevator lighting and control installation did not meet all requirements of the applicable codes. This could affect any occupant of the elevator during an outage of the normal power system.


Findings include:

On August 24, 2015 at 11:00 AM, while accompanied by the MS, the surveyor observed the elevator cab lights in Elevators 7 and 8 are not fed from the Life Safety branch of emergency power in accordance with NFPA-70, Section 517-32, and the elevators are not equipped with cab lighting disconnects in the Elevator Equipment Rooms in accordance with NFPA-70, Section 620-53.

Based on observations made during the survey walk through the surveyor found that the elevators did not meet all of the requirements of ANSI/ASME A17.3. This could affect any occupants of the facility using the elevator if proper safety equipment is not installed on each elevator.

Findings include:

1. On August 24, 2015 at 11:00 AM, while accompanied by the MS, the surveyor observed the Elevator Machine Room for elevator 7 and 8 does not have a heat detector within 2 feet of each sprinkler head, tied to a shunt trip, as required by NFPA-72, Section 3-9.4, and ASME A17.1, Section 102.2(c)(3).