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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. Corrected 04/12/16

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. Corrected 04/12/16

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.