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Based on random observation during the survey walk-through, not all interior finishes comply with applicable requirements of the Life Safety Code. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, because the lack of compliance can expose occupants to harmful fire and smoke conditions.

Findings include:

A. On July 25, 2012 at approximately 1:15pm, the Rehab Storage room on the 2nd floor was observed to have unfinished wood pegboard on one wall which was estimated by staff to constitute more than 10% of the wall and ceiling surface area and does not comply with the minimum Class B flame spread rating required by 19.3.3.2 and 10.2.3. The material does not otherwise comply with 10.2.5 as being minimum Class C flame spread rating if less than 10% of the wall and ceiling surface area.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, because the lack of protection could result in smoke compromising the facility's exit access corridors.

Findings include:

A. On 7/25/12 at approximately 2:00pm, the non-sprinklered 1st floor nurse station near the NE Stair which was reported as not being staffed 24/7 was observed to be open to the corridor and not provided with sprinkler protection and the space and the corridors onto which it opens in the smoke compartment were not provided with smoke detection to comply with 19.3.6.1 Exception No. 6.

B. On 7/25/12 at approximately 2:45pm, the non-sprinklered Ground floor Emergency Room Waiting area south of the NE Stair was observed to be open to the corridor and was not provided with smoke detection to comply with 19.3.6.1 Exception No. 7.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients within the smoke compartment, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. On 7/25/12 at approximately 3:00pm, it was observed that the corridor door at the Ground floor Doctor's Lounge is not resistant to the passage of smoke to comply with 19.3.6.3 because the door lacked a stop at the hinge and head sides.

Based on random observation during the survey walk-through on July 24-26, 2012, not all vertical opeingings are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels.

Findings include:

A. On the morning of 7/25/12 at approximately 9am, the partial door accessing the interstitial space below the elevator machine room at Penthouse "A" was observed not to comply with ANSI/ASME A17.3, 2.1.1 and NFPA 101-2000, 9.4.2.2 & 19.3.1.1 because the door was not self-closing to a latched condition due to the door binding in the frame.

B. On the morning of 7/25/12 at approximately 9am, the shaft utilized for the diesel fuel piping serving the genertor and boilers at Penthouse "A" was observed not to be sealed at the penthouse floor to comply with NFPA 101-2000, 19.3.1.1.

C. On the morning of 7/25/12 at approximately 9am, the inactive door of the pair of doors accessing the elevator machine room at Penthouse "A" was observed to be left open and not in compliance with ANSI/ASME A17.3, 2.1.1 and NFPA 101-2000, 9.4.2.2 & 19.3.1.1. Self-closing and automatic flush bolt hardware was not confirmed.

D. On the morning of 7/25/12 at approximately 9am, the elevator machine room at penthouse "A" was observed to have a duct penetrating the wall into the mechanical space and then through the roof which was not equipped with a fire damper at the shaft enclosure wall to comply with ANSI/ASME A17.3, 2.1.1 and NFPA 101-2000, 9.4.2.2 & 19.3.1.1.

E. On the morning of 7/25/12 at approximately 9:45am, the "pipe space" shaft located within the 4th floor Surgery area was observed to have unsealed penetrations at the enclosing walls and the door to the space was not self-closing to a positive latching condition.

F. On the morning of 7/25/12 at approximately 10:45am while reviewing the new Surgery construction area of the 3rd floor, floor penetrations created from the removal of ducts to above and below were observed without temporary closure to protect the occuppied areas from the construction activities and any exposure to the spread of fire or smoke originating in the construction area.

G. On the afternoon of 7/25/12 at approximately 1:15pm, the Telephone equipment closet near the Staff Education Office on the 2nd floor was observed with floor penetrations which were not sealed to maintain the required fire rating of the floor.

H. On the afternoon of 7/25/12 at approximately 1:20pm, the Linen room with the "pipe chase" shaft behind it was observed to have a grille/duct penetration which could not be confirmed to have a fire damper.

I. On the morning of 7/26/12 at approximately 8:15am, the Medical Records room in the Basement was observed to have penetrations through the floor above for orange data cables which were not sealed to maintain the required fire rating of the floor.

J. On the morning of 7/26/12 at approximately 8:20am, the Environmental Services Storage room in the Basement was observed to have penetrations through the floor above which served the X-ray equipment sealed with a yellow polyurethane spray foam material which could not be confirmed to carry a fire restance rating to maintain the required fire rating of the floor.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. On 7/25/12 at approximately 9:30am, the sprinklered 4th floor Surgery Sterile Storage room door was observed to not be self-closing to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

B. On 7/25/12 at approximately 9:30am, the non-sprinklered 4th floor Surgery Soiled Workroom was observed not to be separated by 1-hour rated construction due to the door being a 1/2-lite door which was not fire rated to comply with 19.3.2.1 and 8.4.1.1.

C. On 7/25/12 at approximately 9:50am, the sprinklered 4th floor Surgery Storage room was observed to have a door equipped with an auto-opener that did not have positive latching.

D. On 7/25/12 at approximately 10:15am, the sprinklered 4th floor Soiled Utility room adjacent the Med Gas room near ICU was observed not to have the corridor door self-close to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

E. On 7/25/12 at approximately 11:00am, the 3rd floor non-sprinklered new Surgery construction area was observed not to be separated from other areas to comply with 19.3.2.1 and 8.4.1.1 with 1-hour rated construction due to holes in the wall near the existing elevator wall

F. On 7/25/12 at approximately 11:15am, the 3rd floor non-sprinklered Storage room adjacnt the OB Family & Visitor Nourishment room was observed not to be 1-hour rated including a self-closing door to comply with 19.3.2.1 and 8.4.1.1.

G. On 7/25/12 at approximately 11:20am, the 3rd floor non-sprinklered Linen Storage room was observed not to be 1-hour rated due to the lack of a 3/4-hour rated door assembly to comply with 19.3.2.1 and 8.4.1.1.

H. On 7/25/12 at approximately 11:25am, the sprinklered 3th floor OB Soiled Utility room was observed not to have the corridor door self-close to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

I. On 7/25/12 at approximately 1:15pm, the sprinklered 2nd floor old Hydro Therapy room used as a storage room was observed not to have the corridor door self-closing to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

J. On 7/25/12 at approximately 1:20pm, the sprinklered 2nd floor Storage room near the SW Stair was observed not to have the corridor door self-closing to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

K. On 7/25/12 at approximately 1:25pm, the sprinklered 2nd floor Peds Soiled Utility room was observed not to have the corridor door self-closing to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

L. On 7/25/12 at approximately 1:25pm, the sprinklered 2nd floor Peds Clean Utility room was observed not to have the corridor door self-closing to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

M. On 7/25/12 at approximately 1:30pm, the sprinklered 2nd floor 'Dirty' Utility room at the cross corridor was observed not to have the corridor door self-closing to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

N. On 7/25/12 at approximately 1:35pm, the sprinklered 2nd floor Linen Storage room near room #224 was observed not to have the corridor door self-closing to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

O. On 7/25/12 at approximately 2:00pm, the non-sprinklered 1st floor NW Isolation room was observed to be utilized as a storage room for the Sleep Lab and did not have 1-hour rated separation including a self-closing 3/4-hour rated door to comply with 19.3.2.1, 8.4.1.1.

P. On 7/25/12 at approximately 2:10pm, the sprinklered 1st floor Pharmacy remodeled in 2011 was observed to have three, 3/4-hour rated door assemblies with glazing of "laminated safety glass" which could not be confirmed to be fire resistance rated to comply with 18.3.2.1 and NFPA 80.

Q. On 7/25/12 at approximately 2:30pm, the non-sprinklered Ground floor Emergency Room Soiled Utility room was observed not to be 1-hour rated due to the lack of a 3/4-hour rated door assemblies to comply with 19.3.2.1 and 8.4.1.1.

Based on random observation during the survey walk-through, not all exits are enclosed in accordance with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect any patients, as well as any staff and visitors present required to utilize the stair, by preventing those occupants from reaching an exit from the building.

Findings include:

A. On 7/25/12 at approximately 9:00am, the east stair from Penthouse 'B' that discharges to the 3rd floor was observed to have two unsealed conduits at the upper-most landing wall common with the elevator shaft not in compliance with 19.3.1.1, 8.2.5.2 and 7.1.3.2.1.

B. On 7/25/12 at approximately 9:30am, the 4th floor Surgery east stair door was observed not to be labeled as a fire resistive door assembly to comply with 19.3.1.1, 8.2.5.2 and 7.1.3.2.1.

C. On 7/25/12 at approximately 10:00am, the Southwest Stair was observed (at multiple levels) to contain what appear to be a recently installed large conduit/pull boxes in non-compliance with 7.1.3.2.1(e).

Based on random observation during the survey walk-through, exit access was not readily accessible at all times in accordance with 7.1 and 19.2. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit during an event requiring such exiting.

Findings include:

A. On 7/25/12 at approximately 9:30am, it was observed that the eastern stair from the 4th floor Surgery area was not marked with exit signage. However, exiting for the 4th floor Surgery suite area does not comply with 19.2.5.1 Exception No. 4 because horizontal exit access to a corridor or through the 2-hour occupancy separation barrier does not comply with 19.2.5.8 regarding travel distances and intervening rooms created by cross corridor doors.

B. On 7/25/12 at approximately 10:00am, it was observed that the north end of the 4th floor level is defined as the ICU suite. Exiting for the south area corridors cannot exit through a suite to reach the second exit stair to comply with 19.2.5.9. Therefore, the south corridor areas do not have access to two approved exits.

C. On 7/25/12 at approximately 12:30pm, it was observed that the the stair which serves as the exit from Penthouse 'B' discharges at the 3rd floor level into a locked elevator lobby. The door from the stair to the elevator lobby swings against exit travel in non-compliance with 7.2.1.4.3. The elevator lobby had no exit signage to identify the exit path other than a sign on the doors to the OB restricted area and the dental office stating that the doors would unlock upon activation of the fire alarm. These doors did not have delayed egress locking meeting all the requirements of 19.2.2.2.4 Exception No. 2 and 7.2.1.6.1. Activation of the delayed egress function was not available from the elevator lobby/stair discharge side to allow egress.

D. On 7/25/12 at approximately 11:20am, it was observed that the two corridor doors of 3rd floor Nursery were provided with magnetic locking devices that required two hands/two operations to release the door. A push button adjacent the door had to be pressed simultaneously with operating the latching hardware. This arrangement does not comply with 7.2.1.5.4 relative to two operations to release the door and 7.2.1.6.2 relative to the operation of access controlled egress door special locking devices.

E. On the date of 7/25/12, it was observed the exit access doors were equipped with hardware which requires more than one operation to release the door when locked which does not comply with 7.2.1.5.4. Locations observed include but are not necessarily limited to the following:

1. The 3rd floor Linen Storage room has both a dead bolt lock and a latch.

2. The 2nd floor Patient Education Office has both a dead bolt lock and a latch.

3. The 2nd floor Soiled Utility room has both a dead bolt lock and a latch.

4. The 2nd floor Rehab Storage room has both a dead bolt lock and a latch. The dead bolt lock will not permit egress when locked.

5. The 1st floor rooms 101, 102, 103, 113, 114, 115, 117, 118, 119, 120 have both dead bolt locks and door latches.

6. The 1st floor Linen Storage room near the smoke barrier has both a dead bolt lock and a latch.

7. An office east of the 1st floor Gift Shop has both a dead bolt lock and a latch.

8. The old Pharmacy area on the Ground floor has both a dead bolt lock and a latch.

9. The Ground floor Medical Records storage room actively used door has both a dead bolt lock and a latch. The door from this room which is provided with exit signage has a desk blocking use of the door.

Fire separation barriers are not maintained in accordance with 19.1.2.3 and 8.2.3. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the different occupancies.

Findings include:

A. On 7/25/12 at approximately 9:15am, the 4th floor 2-hour barrier doors between the Hospital Building "B" corridor and the adjacent Business Building "C" corridor were observed to not be positive latching upon closing to comply with 8.2.3.2.1.

B. On 7/25/12 at approximately 3:15pm, the Ground floor 2-hour barrier doors between the Hospital Building "B" corridor and the adjacent Business Building "C" corridor were observed to not be positive latching upon closing to comply with 8.2.3.2.1.

Emergency illumination in accordance with 19.2.9.1 and 7.9 is not provided. Failure to provide adequate lighting during the failure of normal power can prevent patients, staff and any visitors from performing needed functions and/or unimpeded exiting.

Findings include:

A. On 7/25/12 at approximately 3:00pm, the facility could not confirm that the exit discharge lighting at the patio areaway at the discharge of the exits from the Ground floor Lab and the southwest exit door could not be confirmed to be connected to the emergency power system to comply with 7.9.1.1. All exit discharge lighting requires confirmation that it is connected to the emergency power system.

Based on random observation during the survey walk-through, exit signs were not fully visible to designate the path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. On 7/25/12 at approximately 10:00am, it was observed that exit signage on the 4th floor was not visible to comply with 19.2.10.1 from opposite ends of the corridors due to the placement of other signage.

B. On 7/25/12 at approximately 11:20am, it was observed that the exit sign intended to designate the smoke barrier door at the east end of the LDRP corridor as the exit path was not located above the egress door of the double egress cross corridor doors to clearly define the exit door/path.

C. On 7/25/12 at approximately 1:00pm, it was observed that the exit sign located within the 3rd floor tenant dental suite was not illuminated.

D. On 7/25/12 at approximately 2:10pm, it was observed that the 1st floor Pharmacy is subdivided with a roll-down shutter at the door opening and this opening is marked with exit signage. The shutter does not comply with 19.2.2.2.1 and 7.2.1.4.1 as a permitted door in a means of egress and therefore can not be marked with exit signage.

E. On 7/25/12 at approximately 3:00pm, it was observed that the second required exit access for the Ground floor Lab suite was not identified by exit signage.

Based on random observation during the survey walk through, not all areas of the building fire alarm system are installed in accordance with 19.3.4 and NFPA 72-1999. This could effect all building occupants if the fire alarm system does not initiate an alarm without delay or the components can not be located during a fire emergency.

Findings include:

A. On 7/25/12 at approximately 11:15am, it was observed that the SW Stair on the 3rd floor lacked a manual pull station within 5' of the exit to comply with 9.6.2.3 and NFPA 72-1999, 2-8.2.2.

B. On 7/25/12 at approximately 1:40pm, it was observed that panel "C2-A" at the 2nd floor Electrical panel room at the cross corridor north of the nurse station contained four circuits (23, 25, 27, 29) labeled as serving the fire alarm system. These circuits were not clearly destinguished by red markings and were not equipped with lock-on devices to comply with NFPA 72-1999, 1-5.2.5.2.

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA 13-1999 and NFPA 25-1998. This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

A. On 7/25/12 at approximately 10:00am, it was observed that 18" below the sprinkler heads to stored materilas was not being maintained in accordance with NFPA 13-1999, 5-6.6 at the 4th floor Surgery Supply room located adjacent the 2-hour occupancy separation barrier.

B. On 7/25/12 at approximately 1:30pm, it was observed that a sprinkler head located in the 2nd floor Shower room #2 was missing the concealed head escutcheon to comply with NFPA 25-1998, 2-4.1.8.

C. On 7/25/12 at approximately 1:35pm, it was observed that the 2nd floor electrical panel closet at the cross corridor north of the nurse station was not provided with sprinkler coverage in a smoke compartment considered to be fully sprinkler protected.

D. On 7/24/12 at approximately 2:00pm, it was observed during document review of the quarterly sprinkler system inspections that the 6/19/12 (and previous) fire pump inspection reports noted deficiencies as follows which have not been addressed:

1. "Circulation relief valve not working and should be replaced."

2. "Valve needed in sensing line to allow for starting of pump."

3. "Could not reach 150% due to low suction pressure."

4. "No coupling guard on pump."

E. On 7/24/12 at approximately 2:00pm, it was observed during document review of the quarterly sprinkler system inspections that no documentation that the fire pump was run on emergency power was available to comply with NFPA 25-1998, 5-3.3.4.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99. This deficiency could affect all occupants of the smoke compartment they are located in because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials.

Findings include:

A. On 7/25/12 at approximately 2:30pm, portable medical gas tanks were observed being stored with combustibles in the three adjacent non-sprinklered small closets located within the Ground floor Radiology suite not in compliance with NFPA 99 1999 8-3.1.11.2(c)(2).

Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99-1999. These deficiencies could affect all occupants of the smoke compartment they are located in because the lack of proper identification of the medical gas system components and the areas they serve could contribute to inadvertant interruption of the supply or delay in shut-down when required.

Findings include:

A. On 7/25/12 at approximately 9:45am, it was observed that the medical gas valve for the 4th floor OR #5 was labeled, but OR #5 was not identified with signage or labeling to comply with NFPA 99-1999, 4-3.1.2.14(b).

B. On 7/25/12 at approximately 10:45am, it was observed that two medical gas valves located in the 4th floor west corridor outside Day Surgery were not labeled to identify the areas served to comply with NFPA 99-1999, 4-3.1.2.14(b).

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3 and 8.3.

Findings include:

A. On 7/25/12 at approximately 10:40am, a duct penetrating the smoke barrier wall between the non-sprinklered 4th floor corridor and the ICU Med room was observed not to be equipped with a smoke damper to comply with 19.3.7.3. and 8.3.5.

Based upon random observation and document review, the facility's emergency generator system is not maintained in accordance with NFPA 99-1999 and NFPA 110-1999.

Findings include:

A. On 7/24/12 at approximately 2:00pm, it was observed that the monthly routine maintenance and operational testing of generator #2 located on the roof is not documented in accordance with NFPA 110-1999, 6-4, and suggested log A-6-4.1(a) and procedures A-6-4.1(b) because no documentation was available for review at the time of the survey.

B. On 7/24/12 at approximately 2:00pm, it was observed that the monthly routine maintenance and operational testing of generator #1 located in the Basement Generator room is not documented in accordance with NFPA 110-1999, 6-4, and suggested log A-6-4.1(a) and procedures A-6-4.1(b).

1. Available documentation indicates that a 30% load is achieved when 62.4 Amp reading is recorded during monthly testing. The generator is noted to be rated at 300KW, 208V, 3 phase. (300,000 rated watts)/(120 volts per phase) = 2500 amps total; 2500 amps/3 = 833.3 amps per phase; 833.3 x .3 (30%) = 250 amp load per phase required to achieve 30% load. Based upon available documentation, the generator has not been loaded to the minimum 30% of capacity during the last year and no documentation of an annual load bank test is available to comply with NFPA 110-1999, 6-4.2.

C. On 7/24/12 at approximately 2:00pm, it was observed that the weekly visual inspection and maintenance of the generator is not documented in accordance with NFPA 110-1999, 6-3, and suggested log A-6-3.1(a) and procedures A-6-3.1(b).

1. Weekly and monthly inspection and testing of the starting battery electrolyte levels and specific gravity is not documented in accordance with NFPA 110-1999, 6-3.6.

D. On 7/26/12 at approximately 8:30am, it was observed that generator #2 located at the roof was not equipped with a battery heater to maintain battery temperature at a minimum of 50 degrees F and to automatically shut off when battery temperature reaches 90 degrees F and the battery heater is deactivated while the prime mover is running to comply with NFPA 110-1999, 3-3.1.

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

Findings include:

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

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA 99-1999 and NFPA 70-1999, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Findings include:

A. During the survey walk-through on 7/25/12, it was observed that electrical panels throughout the building did not appear to be separated into Life Safety panels, Critical panels, and Equipment panels. The following observations could not confirm that the loads specifically allowed to be on each of the branch panels was in compliance with NFPA 99-1999, 3-4.2.2.2 and NFPA 70-1999, Section 517.

1. At approximately 10:30am, panels in the 4th floor ICU appeared to be originally labeled "C4-A" and later also tagged with a "Life Safety" label. The "C4-A" designation appeared to indicate the panel to be a "Critical branch" panel and not a "Life Safety branch" panel because it was serving circuits assigned to receptacles, .

2. At approximately 1:40pm, the "C2-A" panel at the 2nd floor Electrical panel room at the cross corridor north of the nurse station was observed to have four circuits (23, 25, 27, 29) labeled as serving the fire alarm system. This panel was also labeled as a "Life Safety" panel but had other circuits which appeared not be be permitted to be on a "Life Safety" branch panel.

3. At approximately 2:45pm, the "CG-A" panel at the Ground floor Emergency room was observed to also be tagged with a "Life Safety" label. This panel included circuits labeled as serving "exhaust fans", "fridge", "roll-up door". The "LG-C" panel was also tagged with a "Life Safety" label and included circuits labeled as serving "lights", "receptacles", "air curtain".

Based on random observation during the survey walk-thru, electrical wiring and equipment was not installed and maintained in accordance with NFPA 70 National Electric Code and NFPA 101, 9.1.2. These deficiencies could result in exposure of occupants to electrical shock.

Findings include:

A. On 7/26/12 at approximately 8:00am, it was observed in the Basement switchgear room that a conduit containing wiring had been disconnected and terminated with wire nuts without enclosure in a covered electrical box.

B. On 7/26/12 at approximately 8:15am, it was observed in the Basement Storage room (original electric boiler room) that a conduit containing wiring had been disconnected and terminated with wire nuts without enclosure in a covered electrical box.

Based on random observation during the survey walk-through, not all interior finishes comply with applicable requirements of the Life Safety Code. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, because the lack of compliance can expose occupants to harmful fire and smoke conditions.

Findings include:

A. On July 25, 2012 at approximately 1:15pm, the Rehab Storage room on the 2nd floor was observed to have unfinished wood pegboard on one wall which was estimated by staff to constitute more than 10% of the wall and ceiling surface area and does not comply with the minimum Class B flame spread rating required by 19.3.3.2 and 10.2.3. The material does not otherwise comply with 10.2.5 as being minimum Class C flame spread rating if less than 10% of the wall and ceiling surface area.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, because the lack of protection could result in smoke compromising the facility's exit access corridors.

Findings include:

A. On 7/25/12 at approximately 2:00pm, the non-sprinklered 1st floor nurse station near the NE Stair which was reported as not being staffed 24/7 was observed to be open to the corridor and not provided with sprinkler protection and the space and the corridors onto which it opens in the smoke compartment were not provided with smoke detection to comply with 19.3.6.1 Exception No. 6.

B. On 7/25/12 at approximately 2:45pm, the non-sprinklered Ground floor Emergency Room Waiting area south of the NE Stair was observed to be open to the corridor and was not provided with smoke detection to comply with 19.3.6.1 Exception No. 7.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients within the smoke compartment, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. On 7/25/12 at approximately 3:00pm, it was observed that the corridor door at the Ground floor Doctor's Lounge is not resistant to the passage of smoke to comply with 19.3.6.3 because the door lacked a stop at the hinge and head sides.

Based on random observation during the survey walk-through on July 24-26, 2012, not all vertical opeingings are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the floor levels.

Findings include:

A. On the morning of 7/25/12 at approximately 9am, the partial door accessing the interstitial space below the elevator machine room at Penthouse "A" was observed not to comply with ANSI/ASME A17.3, 2.1.1 and NFPA 101-2000, 9.4.2.2 & 19.3.1.1 because the door was not self-closing to a latched condition due to the door binding in the frame.

B. On the morning of 7/25/12 at approximately 9am, the shaft utilized for the diesel fuel piping serving the genertor and boilers at Penthouse "A" was observed not to be sealed at the penthouse floor to comply with NFPA 101-2000, 19.3.1.1.

C. On the morning of 7/25/12 at approximately 9am, the inactive door of the pair of doors accessing the elevator machine room at Penthouse "A" was observed to be left open and not in compliance with ANSI/ASME A17.3, 2.1.1 and NFPA 101-2000, 9.4.2.2 & 19.3.1.1. Self-closing and automatic flush bolt hardware was not confirmed.

D. On the morning of 7/25/12 at approximately 9am, the elevator machine room at penthouse "A" was observed to have a duct penetrating the wall into the mechanical space and then through the roof which was not equipped with a fire damper at the shaft enclosure wall to comply with ANSI/ASME A17.3, 2.1.1 and NFPA 101-2000, 9.4.2.2 & 19.3.1.1.

E. On the morning of 7/25/12 at approximately 9:45am, the "pipe space" shaft located within the 4th floor Surgery area was observed to have unsealed penetrations at the enclosing walls and the door to the space was not self-closing to a positive latching condition.

F. On the morning of 7/25/12 at approximately 10:45am while reviewing the new Surgery construction area of the 3rd floor, floor penetrations created from the removal of ducts to above and below were observed without temporary closure to protect the occuppied areas from the construction activities and any exposure to the spread of fire or smoke originating in the construction area.

G. On the afternoon of 7/25/12 at approximately 1:15pm, the Telephone equipment closet near the Staff Education Office on the 2nd floor was observed with floor penetrations which were not sealed to maintain the required fire rating of the floor.

H. On the afternoon of 7/25/12 at approximately 1:20pm, the Linen room with the "pipe chase" shaft behind it was observed to have a grille/duct penetration which could not be confirmed to have a fire damper.

I. On the morning of 7/26/12 at approximately 8:15am, the Medical Records room in the Basement was observed to have penetrations through the floor above for orange data cables which were not sealed to maintain the required fire rating of the floor.

J. On the morning of 7/26/12 at approximately 8:20am, the Environmental Services Storage room in the Basement was observed to have penetrations through the floor above which served the X-ray equipment sealed with a yellow polyurethane spray foam material which could not be confirmed to carry a fire restance rating to maintain the required fire rating of the floor.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. On 7/25/12 at approximately 9:30am, the sprinklered 4th floor Surgery Sterile Storage room door was observed to not be self-closing to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

B. On 7/25/12 at approximately 9:30am, the non-sprinklered 4th floor Surgery Soiled Workroom was observed not to be separated by 1-hour rated construction due to the door being a 1/2-lite door which was not fire rated to comply with 19.3.2.1 and 8.4.1.1.

C. On 7/25/12 at approximately 9:50am, the sprinklered 4th floor Surgery Storage room was observed to have a door equipped with an auto-opener that did not have positive latching.

D. On 7/25/12 at approximately 10:15am, the sprinklered 4th floor Soiled Utility room adjacent the Med Gas room near ICU was observed not to have the corridor door self-close to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

E. On 7/25/12 at approximately 11:00am, the 3rd floor non-sprinklered new Surgery construction area was observed not to be separated from other areas to comply with 19.3.2.1 and 8.4.1.1 with 1-hour rated construction due to holes in the wall near the existing elevator wall

F. On 7/25/12 at approximately 11:15am, the 3rd floor non-sprinklered Storage room adjacnt the OB Family & Visitor Nourishment room was observed not to be 1-hour rated including a self-closing door to comply with 19.3.2.1 and 8.4.1.1.

G. On 7/25/12 at approximately 11:20am, the 3rd floor non-sprinklered Linen Storage room was observed not to be 1-hour rated due to the lack of a 3/4-hour rated door assembly to comply with 19.3.2.1 and 8.4.1.1.

H. On 7/25/12 at approximately 11:25am, the sprinklered 3th floor OB Soiled Utility room was observed not to have the corridor door self-close to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

I. On 7/25/12 at approximately 1:15pm, the sprinklered 2nd floor old Hydro Therapy room used as a storage room was observed not to have the corridor door self-closing to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

J. On 7/25/12 at approximately 1:20pm, the sprinklered 2nd floor Storage room near the SW Stair was observed not to have the corridor door self-closing to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

K. On 7/25/12 at approximately 1:25pm, the sprinklered 2nd floor Peds Soiled Utility room was observed not to have the corridor door self-closing to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

L. On 7/25/12 at approximately 1:25pm, the sprinklered 2nd floor Peds Clean Utility room was observed not to have the corridor door self-closing to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

M. On 7/25/12 at approximately 1:30pm, the sprinklered 2nd floor 'Dirty' Utility room at the cross corridor was observed not to have the corridor door self-closing to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

N. On 7/25/12 at approximately 1:35pm, the sprinklered 2nd floor Linen Storage room near room #224 was observed not to have the corridor door self-closing to a latched condition to comply with 19.3.2.1, 8.4.1.2 and 8.2.4.3.5.

O. On 7/25/12 at approximately 2:00pm, the non-sprinklered 1st floor NW Isolation room was observed to be utilized as a storage room for the Sleep Lab and did not have 1-hour rated separation including a self-closing 3/4-hour rated door to comply with 19.3.2.1, 8.4.1.1.

P. On 7/25/12 at approximately 2:10pm, the sprinklered 1st floor Pharmacy remodeled in 2011 was observed to have three, 3/4-hour rated door assemblies with glazing of "laminated safety glass" which could not be confirmed to be fire resistance rated to comply with 18.3.2.1 and NFPA 80.

Q. On 7/25/12 at approximately 2:30pm, the non-sprinklered Ground floor Emergency Room Soiled Utility room was observed not to be 1-hour rated due to the lack of a 3/4-hour rated door assemblies to comply with 19.3.2.1 and 8.4.1.1.

Based on random observation during the survey walk-through, not all exits are enclosed in accordance with 19.3.1.1 and 8.2.5.2 and 7.1.3.2. These deficiencies could affect any patients, as well as any staff and visitors present required to utilize the stair, by preventing those occupants from reaching an exit from the building.

Findings include:

A. On 7/25/12 at approximately 9:00am, the east stair from Penthouse 'B' that discharges to the 3rd floor was observed to have two unsealed conduits at the upper-most landing wall common with the elevator shaft not in compliance with 19.3.1.1, 8.2.5.2 and 7.1.3.2.1.

B. On 7/25/12 at approximately 9:30am, the 4th floor Surgery east stair door was observed not to be labeled as a fire resistive door assembly to comply with 19.3.1.1, 8.2.5.2 and 7.1.3.2.1.

C. On 7/25/12 at approximately 10:00am, the Southwest Stair was observed (at multiple levels) to contain what appear to be a recently installed large conduit/pull boxes in non-compliance with 7.1.3.2.1(e).

Based on random observation during the survey walk-through, exit access was not readily accessible at all times in accordance with 7.1 and 19.2. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit during an event requiring such exiting.

Findings include:

A. On 7/25/12 at approximately 9:30am, it was observed that the eastern stair from the 4th floor Surgery area was not marked with exit signage. However, exiting for the 4th floor Surgery suite area does not comply with 19.2.5.1 Exception No. 4 because horizontal exit access to a corridor or through the 2-hour occupancy separation barrier does not comply with 19.2.5.8 regarding travel distances and intervening rooms created by cross corridor doors.

B. On 7/25/12 at approximately 10:00am, it was observed that the north end of the 4th floor level is defined as the ICU suite. Exiting for the south area corridors cannot exit through a suite to reach the second exit stair to comply with 19.2.5.9. Therefore, the south corridor areas do not have access to two approved exits.

C. On 7/25/12 at approximately 12:30pm, it was observed that the the stair which serves as the exit from Penthouse 'B' discharges at the 3rd floor level into a locked elevator lobby. The door from the stair to the elevator lobby swings against exit travel in non-compliance with 7.2.1.4.3. The elevator lobby had no exit signage to identify the exit path other than a sign on the doors to the OB restricted area and the dental office stating that the doors would unlock upon activation of the fire alarm. These doors did not have delayed egress locking meeting all the requirements of 19.2.2.2.4 Exception No. 2 and 7.2.1.6.1. Activation of the delayed egress function was not available from the elevator lobby/stair discharge side to allow egress.

D. On 7/25/12 at approximately 11:20am, it was observed that the two corridor doors of 3rd floor Nursery were provided with magnetic locking devices that required two hands/two operations to release the door. A push button adjacent the door had to be pressed simultaneously with operating the latching hardware. This arrangement does not comply with 7.2.1.5.4 relative to two operations to release the door and 7.2.1.6.2 relative to the operation of access controlled egress door special locking devices.

E. On the date of 7/25/12, it was observed the exit access doors were equipped with hardware which requires more than one operation to release the door when locked which does not comply with 7.2.1.5.4. Locations observed include but are not necessarily limited to the following:

1. The 3rd floor Linen Storage room has both a dead bolt lock and a latch.

2. The 2nd floor Patient Education Office has both a dead bolt lock and a latch.

3. The 2nd floor Soiled Utility room has both a dead bolt lock and a latch.

4. The 2nd floor Rehab Storage room has both a dead bolt lock and a latch. The dead bolt lock will not permit egress when locked.

5. The 1st floor rooms 101, 102, 103, 113, 114, 115, 117, 118, 119, 120 have both dead bolt locks and door latches.

6. The 1st floor Linen Storage room near the smoke barrier has both a dead bolt lock and a latch.

7. An office east of the 1st floor Gift Shop has both a dead bolt lock and a latch.

8. The old Pharmacy area on the Ground floor has both a dead bolt lock and a latch.

9. The Ground floor Medical Records storage room actively used door has both a dead bolt lock and a latch. The door from this room which is provided with exit signage has a desk blocking use of the door.

Fire separation barriers are not maintained in accordance with 19.1.2.3 and 8.2.3. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by not providing the intended fire barrier protection between the different occupancies.

Findings include:

A. On 7/25/12 at approximately 9:15am, the 4th floor 2-hour barrier doors between the Hospital Building "B" corridor and the adjacent Business Building "C" corridor were observed to not be positive latching upon closing to comply with 8.2.3.2.1.

B. On 7/25/12 at approximately 3:15pm, the Ground floor 2-hour barrier doors between the Hospital Building "B" corridor and the adjacent Business Building "C" corridor were observed to not be positive latching upon closing to comply with 8.2.3.2.1.

Emergency illumination in accordance with 19.2.9.1 and 7.9 is not provided. Failure to provide adequate lighting during the failure of normal power can prevent patients, staff and any visitors from performing needed functions and/or unimpeded exiting.

Findings include:

A. On 7/25/12 at approximately 3:00pm, the facility could not confirm that the exit discharge lighting at the patio areaway at the discharge of the exits from the Ground floor Lab and the southwest exit door could not be confirmed to be connected to the emergency power system to comply with 7.9.1.1. All exit discharge lighting requires confirmation that it is connected to the emergency power system.

Based on random observation during the survey walk-through, exit signs were not fully visible to designate the path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. On 7/25/12 at approximately 10:00am, it was observed that exit signage on the 4th floor was not visible to comply with 19.2.10.1 from opposite ends of the corridors due to the placement of other signage.

B. On 7/25/12 at approximately 11:20am, it was observed that the exit sign intended to designate the smoke barrier door at the east end of the LDRP corridor as the exit path was not located above the egress door of the double egress cross corridor doors to clearly define the exit door/path.

C. On 7/25/12 at approximately 1:00pm, it was observed that the exit sign located within the 3rd floor tenant dental suite was not illuminated.

D. On 7/25/12 at approximately 2:10pm, it was observed that the 1st floor Pharmacy is subdivided with a roll-down shutter at the door opening and this opening is marked with exit signage. The shutter does not comply with 19.2.2.2.1 and 7.2.1.4.1 as a permitted door in a means of egress and therefore can not be marked with exit signage.

E. On 7/25/12 at approximately 3:00pm, it was observed that the second required exit access for the Ground floor Lab suite was not identified by exit signage.

Based on random observation during the survey walk through, not all areas of the building fire alarm system are installed in accordance with 19.3.4 and NFPA 72-1999. This could effect all building occupants if the fire alarm system does not initiate an alarm without delay or the components can not be located during a fire emergency.

Findings include:

A. On 7/25/12 at approximately 11:15am, it was observed that the SW Stair on the 3rd floor lacked a manual pull station within 5' of the exit to comply with 9.6.2.3 and NFPA 72-1999, 2-8.2.2.

B. On 7/25/12 at approximately 1:40pm, it was observed that panel "C2-A" at the 2nd floor Electrical panel room at the cross corridor north of the nurse station contained four circuits (23, 25, 27, 29) labeled as serving the fire alarm system. These circuits were not clearly destinguished by red markings and were not equipped with lock-on devices to comply with NFPA 72-1999, 1-5.2.5.2.

Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA 13-1999 and NFPA 25-1998. This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:

A. On 7/25/12 at approximately 10:00am, it was observed that 18" below the sprinkler heads to stored materilas was not being maintained in accordance with NFPA 13-1999, 5-6.6 at the 4th floor Surgery Supply room located adjacent the 2-hour occupancy separation barrier.

B. On 7/25/12 at approximately 1:30pm, it was observed that a sprinkler head located in the 2nd floor Shower room #2 was missing the concealed head escutcheon to comply with NFPA 25-1998, 2-4.1.8.

C. On 7/25/12 at approximately 1:35pm, it was observed that the 2nd floor electrical panel closet at the cross corridor north of the nurse station was not provided with sprinkler coverage in a smoke compartment considered to be fully sprinkler protected.

D. On 7/24/12 at approximately 2:00pm, it was observed during document review of the quarterly sprinkler system inspections that the 6/19/12 (and previous) fire pump inspection reports noted deficiencies as follows which have not been addressed:

1. "Circulation relief valve not working and should be replaced."

2. "Valve needed in sensing line to allow for starting of pump."

3. "Could not reach 150% due to low suction pressure."

4. "No coupling guard on pump."

E. On 7/24/12 at approximately 2:00pm, it was observed during document review of the quarterly sprinkler system inspections that no documentation that the fire pump was run on emergency power was available to comply with NFPA 25-1998, 5-3.3.4.

Based on random observation during the survey walk-through, not all portable medical gases are stored in accordance with NFPA 99. This deficiency could affect all occupants of the smoke compartment they are located in because the medical gas tanks could contribute to any combustion which might occur with the adjacent combustible materials.

Findings include:

A. On 7/25/12 at approximately 2:30pm, portable medical gas tanks were observed being stored with combustibles in the three adjacent non-sprinklered small closets located within the Ground floor Radiology suite not in compliance with NFPA 99 1999 8-3.1.11.2(c)(2).

Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99-1999. These deficiencies could affect all occupants of the smoke compartment they are located in because the lack of proper identification of the medical gas system components and the areas they serve could contribute to inadvertant interruption of the supply or delay in shut-down when required.

Findings include:

A. On 7/25/12 at approximately 9:45am, it was observed that the medical gas valve for the 4th floor OR #5 was labeled, but OR #5 was not identified with signage or labeling to comply with NFPA 99-1999, 4-3.1.2.14(b).

B. On 7/25/12 at approximately 10:45am, it was observed that two medical gas valves located in the 4th floor west corridor outside Day Surgery were not labeled to identify the areas served to comply with NFPA 99-1999, 4-3.1.2.14(b).

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3 and 8.3.

Findings include:

A. On 7/25/12 at approximately 10:40am, a duct penetrating the smoke barrier wall between the non-sprinklered 4th floor corridor and the ICU Med room was observed not to be equipped with a smoke damper to comply with 19.3.7.3. and 8.3.5.

Based upon random observation and document review, the facility's emergency generator system is not maintained in accordance with NFPA 99-1999 and NFPA 110-1999.

Findings include:

A. On 7/24/12 at approximately 2:00pm, it was observed that the monthly routine maintenance and operational testing of generator #2 located on the roof is not documented in accordance with NFPA 110-1999, 6-4, and suggested log A-6-4.1(a) and procedures A-6-4.1(b) because no documentation was available for review at the time of the survey.

B. On 7/24/12 at approximately 2:00pm, it was observed that the monthly routine maintenance and operational testing of generator #1 located in the Basement Generator room is not documented in accordance with NFPA 110-1999, 6-4, and suggested log A-6-4.1(a) and procedures A-6-4.1(b).

1. Available documentation indicates that a 30% load is achieved when 62.4 Amp reading is recorded during monthly testing. The generator is noted to be rated at 300KW, 208V, 3 phase. (300,000 rated watts)/(120 volts per phase) = 2500 amps total; 2500 amps/3 = 833.3 amps per phase; 833.3 x .3 (30%) = 250 amp load per phase required to achieve 30% load. Based upon available documentation, the generator has not been loaded to the minimum 30% of capacity during the last year and no documentation of an annual load bank test is available to comply with NFPA 110-1999, 6-4.2.

C. On 7/24/12 at approximately 2:00pm, it was observed that the weekly visual inspection and maintenance of the generator is not documented in accordance with NFPA 110-1999, 6-3, and suggested log A-6-3.1(a) and procedures A-6-3.1(b).

1. Weekly and monthly inspection and testing of the starting battery electrolyte levels and specific gravity is not documented in accordance with NFPA 110-1999, 6-3.6.

D. On 7/26/12 at approximately 8:30am, it was observed that generator #2 located at the roof was not equipped with a battery heater to maintain battery temperature at a minimum of 50 degrees F and to automatically shut off when battery temperature reaches 90 degrees F and the battery heater is deactivated while the prime mover is running to comply with NFPA 110-1999, 3-3.1.

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

Findings include:

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

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA 99-1999 and NFPA 70-1999, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Findings include:

A. During the survey walk-through on 7/25/12, it was observed that electrical panels throughout the building did not appear to be separated into Life Safety panels, Critical panels, and Equipment panels. The following observations could not confirm that the loads specifically allowed to be on each of the branch panels was in compliance with NFPA 99-1999, 3-4.2.2.2 and NFPA 70-1999, Section 517.

1. At approximately 10:30am, panels in the 4th floor ICU appeared to be originally labeled "C4-A" and later also tagged with a "Life Safety" label. The "C4-A" designation appeared to indicate the panel to be a "Critical branch" panel and not a "Life Safety branch" panel because it was serving circuits assigned to receptacles, .

2. At approximately 1:40pm, the "C2-A" panel at the 2nd floor Electrical panel room at the cross corridor north of the nurse station was observed to have four circuits (23, 25, 27, 29) labeled as serving the fire alarm system. This panel was also labeled as a "Life Safety" panel but had other circuits which appeared not be be permitted to be on a "Life Safety" branch panel.

3. At approximately 2:45pm, the "CG-A" panel at the Ground floor Emergency room was observed to also be tagged with a "Life Safety" label. This panel included circuits labeled as serving "exhaust fans", "fridge", "roll-up door". The "LG-C" panel was also tagged with a "Life Safety" label and included circuits labeled as serving "lights", "receptacles", "air curtain".

Based on random observation during the survey walk-thru, electrical wiring and equipment was not installed and maintained in accordance with NFPA 70 National Electric Code and NFPA 101, 9.1.2. These deficiencies could result in exposure of occupants to electrical shock.

Findings include:

A. On 7/26/12 at approximately 8:00am, it was observed in the Basement switchgear room that a conduit containing wiring had been disconnected and terminated with wire nuts without enclosure in a covered electrical box.

B. On 7/26/12 at approximately 8:15am, it was observed in the Basement Storage room (original electric boiler room) that a conduit containing wiring had been disconnected and terminated with wire nuts without enclosure in a covered electrical box.