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Based on observation during the survey walk-through, not all portions of the building are of fire resistive construction. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

Findings include:

On October 17, 2016, while accompanied by the DF at the times listed below, it was observed structural steel components which are not fireproofed in accordance with the building's identified construction type. Locations observed include (all Basement):

A. 2:38 PM, Oxygen Storage Room TB121, steal beam above suspended drywall ceiling.

B. 2:58 PM, Shaft TB174 (observed not to be a shaft), steel beams supporting extrerior pavement above.

Based on observation during the survey walk-through, not all exit access corridors are separated from use areas as requred. This deficiency could affect any patients, staff, or visitors in the area by compromising the protection offered by the egress corridors.

Findings include:

On October 19, 2016 at 2:03 PM, while accompanied by the DF, it was observed that Second Floor Interventional Radiology Office T2351, which is open to the adjacent Corridor via a pass-through window, lacks a smoke detector required by Subpart (c) of Exception 1 to 19.3.6.1.

Based on during the survey walk-through, the surveyor finds that not all doors in exit access corridors are resistant to the passage of smoke. These deficiencies could affect any patients, staff, or visitors in the immediate area by allowing smoke or fire to enter the egress corridor.

Findings include:

On October 18, 2016 at 10:15 AM , while accompanied by the FM it was observed that one of the double doors to the Information Suite (IS) on the 13th Floor, was not equipped with positive latching hardware. 19.3.6.3.2

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

Findings include:

A. On October 17, 2016 at 2:15 PM, while accompanied by the D, it was observed that the door to Basement Receiving Room TB142 is not positive latching, as required by 19.3.2.1 and 8.2.3.2.3.1(2), because the door hardware is damaged and not functioning.



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B. On October 18, 2016 at 2:30PM, while accompanied by the FM, it was observed that the door to the Storage Room T8056 near the Food Elevator on the 8th Floor, did not self-close to the latched position. This does not comply with NFPA 101, section 19.3.2.1.

C. On October 19, 2016 at 10:30 AM, while accompanied by the FM it was determined that Patient Room #736 on the 7th Floor is being used as a storage room and the door from the shared Toilet Room #736A was not installed with a self closing device. This does not comply with NFPA 101, section 19.3.2.1.

D. On October 19, 2016 at 11:20 AM, while accompanied by the FM it was determined that the door to the Laundry Closet for the Detox Unit on the 6th Floor was not installed with a self closing device. This does not comply with NFPA 101, section 19.3.2.1.

Based on observation during the survey walk-through and document review, 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 October 17, 2016 at 11:15 AM, while accompanied by the DF, it was determined at the review of the facility's Life Safety Master Plans, dated September 26, 2016, that a series of Exit Stair Shafts are identified as being of "non-rated/non-combustible" construction, and not of minimum 2 hour fire rated construction as required by 8.2.5.4(1). Exit Stairs for which this condition was indicated include:
A. The North Exit Stair.

B. The Northwest Exit Stair.

C. The Central Exit Stair.

D. The West Exit Stair.

E. The East Exit Stair.

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 October 18, 2016 at 10:45 AM, while accompanied by the DF, it was observed that the exterior exit door from First Floor Dining Room T1082, located immediately northeast of the East Exit Stair, was inoperable due to rust or other deleterious materials as prohibited by 7.2.1.5.1. The surveyor notes that this condition was corrected immediately.

B. On October 19, 2016 at 11:00 AM, while accompanied by the DF, it was observed a dead end Corridor of excessive length as prohibited by 19.2.5.10, extending from a locked pair of doors located immediately northwest of Third Floor Elevator 7 to a point in Corridor 3-063 immediately southwest of Third Floor Elevator 3.

C. On October 18, 2016 at 11:13 AM, while accompanied by the DF, it was observed a dead end Corridor of excessive length as prohibited by 19.2.5.10, extending from:

1. The Corridor door to First Floor Medical Director's Office T1242 to a point where First Floor Corridors T1033 and T1149 intersect.

2. The pair of Doors to the designated Emergency Department suite at the north end of First Floor Corridor T1228 to a point where First Floor Corridors T1033 and T1149 intersect.

D. On October 18, 2016 at 9:44 AM, while accompanied by the DF, it was observed that the door to Basement Storage Room TB076 (utilized as a satellite pharmacy) is equipped with a Dutch door which, because the upper leaf and the lower leaf each latch individually into the door frame, requires 2 operations to exit as prohibited by 7.2.1.5.4.



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E. On October 19, 2016 at 11:00 AM, while accompanied by the FM, it was observed that the 5th Floor exit access corridor T5064 near the Central Stair (T5056) by the three Service Elevators has one path of egress. This corridor terminates at the double doors of the ICU East Suite. Due to the lack of exit signage at the pair of cross corridor doors this condition creates a dead end corridor exceeding 30 feet which does not comply with 19.2.5.10.

F. On October 18, 2016 at 10:30 AM, while accompanied by the FM, it was observed on the 12th floor the designated path of egress for the North Wing (Smoke Zone A) to reach the North Exit Stair is directed through a hazardous area (Medical Library Suite). This does not comply with 7.5.2.1, 19.2.1 of NFPA 101 2000 Edition.

Based on observation during the survey walk-through, not all designated or required fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

A. On October 17, 2016 at 1:45 PM, while accompanied by the DF, it was observed pipe and other penetrations, through the designated 2 hour fire rated east wall of Basement Mechanical Room TB153, which are not sealed against the passage of fire as required by 8.2.3.2.4.2. Pipes not sealed include:
1. Medical gas pipes.

2. Sprinkler pipes.

B. On October 17, 2016, while accompanied by the DF, it was observed fire rated doors in designated fire rated partitions which are not self-closing as required by 8.2.3.2.3.1(1). Times observed and locations include (all Basement):

1. 2:26 PM: Electrical Closet TB131.

2. 2:27 PM: Electrical Closet TB132.

Based on observation during the survey walk through, the surveyor found that the fire alarm system and components are not installed properly. This could affect all occupants of the building if the fire alarm system does not operate properly during a fire emergency.

Findings include:

A. On October 18, 2016, at 10:20 AM, while accompanied by the FM, it was observed that in the 12th Floor Waiting Room, a smoke detector was located less than 3'-0 from an air supply diffuser. This does not comply with NFPA 101, Section 9.6 and NFPA 72-1999, 2-3.5.1.

B. On October 18, 2016, at 2:30 PM, while accompanied by the FM, it was observed that the smoke detector located in the 9th Floor, by the smoke barrier wall, near Room 925 was installed too close to a supply diffuser. This does not comply with NFPA 101, Section 9.6 and NFPA 72-1999, 2-3.5.1.

C. On October 19, 2016, at 9:00, AM, while accompanied by the FM it was determined by observations that on the 5th Floor, North Wing contained On-Call sleeping rooms each of the rooms were not installed with fire alarm strobe lights. This does not comply with NFPA 101, Section 19.3.4.1, Section 9.6 and NFPA 72, Section 4-4.4.3.

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 October 17, 2016 at 2:45 PM, while accompanied by the DF, it was observed that the sprinkler head in Basement Janitor's Closet TB125 was partially covered in tape as prohibited by NFPA 13 1999 2-4.1.8.

Based on observation during the survey walk-through, document review, and staff interview, not all portions of the facility's air conditioning and ventilating systems are installed and maintained in a compliant manner. These deficiencies could affect any patients, staff, or visitors in the building because smoke and fire could move between building stories.

Findings include:

A. On October 17, 2016 at 11:15 AM, while accompanied by the DF, the surveyor determined from the facility's Life Safety Master Plans, dated September 26, 2016, that a series of Ventilation and Pipe Shafts, all at least 4 stories in height, are identified as being of "non-rated/non-combustible" construction, and not of minimum 2 hour fire rated construction as required by NFPA 90A 1999 3-3.4.1. Ventilation and Pipe Shafts for which this condition was indicated include but are not limited to (where Room Numbers are shown, refer to First Floor):

1. Shafts at the west and south sides of the North Exit Stair.

2. Shafts at the east and west sides of the Northwest Exit Stair.

3. Shafts T1159 and T1225.

4. Shafts T1053, T1054, and T1055.
5. Shaft surrounding Elevators 3 and 4.

6. Shaft T1100.

7. Shafts immediately west of Elevator 7.

B. On October 18, 2016 at 1:00 PM, while accompanied by the DF, the surveyor determined from a Vendor's Report dated April 29, 2016, that a series of deficiencies related to the installation of fire dampers within the building had been discovered which render the devices out of compliance with NFPA 90A 1999 3-3.4.4. The DF confirmed at that time that the identified deficiencies with the fire damper installations had not yet been corrected.

C. On October 17, 2016 at 1:55 PM, while accompanied by the DF, the surveyor determined from the Life Safety Master Plans dated September 26, 2016 that the south wall of Basement Mechanical Room TB153, which is a part of a Ventilation Shaft which connects at least 4 building stories, does not carry a minimum 2 hour fire rating required by NFPA 90A 1999 3-3.4.1.



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D. On October 18, 2016, at 10:30 AM, while accompanied by the FM, it was observed that the duct penetration thru the ventilation shaft near the Equipment Room on the 11th Floor was observed equipped with a fire damper without a sleeve, which does not provide the proper rated UL tested assembly to comply with 8.2.3.2.4.1 and NFPA 90A 1999 3-3.1.1.

E. On October 18, 2016, at 2:10 PM, while accompanied by the FM, it was observed that the access door for the ventilation shaft located in the Center Stairwell between the 9th and the 10th Floor was not provided with self - closing hardware to comply with 8.2.3.2.1. (b).

F. On October 18, 2016 at 11:10 AM, while accompanied by the FM, it was observed that the ventilation shaft (T11065) on the 11th Floor - Center Core across the Nurse Station contained a duct penetration which lacked a damper installation. This does not comply with 8.2.3.2.4.

Based on observation during the survey walk-through, not all portable medical gases are stored in the required manner. This deficiency could affect any staff or visitors in the area because the the improperly stored gases could contribute to a fire

Findings include:

On October 17, 2016 at 2:45 PM, while accompanied by the DF, it was observed 5 gas tanks, in Basement Janitor's Closet TB125, which are not restrained as required by NFPA 99 1999 4-3.5.2.1.

Based on observation during the survey walk-through, not all medical gas piping systems are installed and maintained as required. These deficiencies could affect any patients in the cited area because the medical gas system could become compromised.

On October 17, 2016 at 2:38 PM, while accompanied by the DF, it was observed pipe and other penetrations, in Basement Oxygen Storage Room TB121, which are not sealed against the passage of fire as required by 8.2.3.2.4.2. and NFPA 99 1999 4-3.1.1.2. Unsealed penetrations (located above a non-fire rated ceiling assembly) observed include:
A. A series of openings in the east clay tile wall.
B. A cable tray in the south clay tile wall.

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 observation, the emergency power was not properly divided into three branches. This could effect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 10/18/16 at 9:25 AM, while accompanied by the RDSS, it was observed that critical panel 1WCP1, circuits 15, 27 and 29 were serving fire alarm loads. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-32.

Based on observation, the facility failed to provide a proper electrical system. This could effect any patient if a transfer switch failed.

Findings include:

On 10/17/16 between 2:15 PM and 315 PM, while accompanied by the RDSS, it was observed the following areas were not equipped with normal power receptacles or receptacles served from two separate critical transfer switches as required by the 1999 Edition of NFPA-99, Section 3-3.2.1.2(a)1.

A. The operating rooms

B. C-section rooms

C. ICU - East rooms

Based on observation during the survey walk-through, not all portions of the building are of fire resistive construction. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

Findings include:

On October 17, 2016, while accompanied by the DF at the times listed below, it was observed structural steel components which are not fireproofed in accordance with the building's identified construction type. Locations observed include (all Basement):

A. 2:38 PM, Oxygen Storage Room TB121, steal beam above suspended drywall ceiling.

B. 2:58 PM, Shaft TB174 (observed not to be a shaft), steel beams supporting extrerior pavement above.

Based on observation during the survey walk-through, not all exit access corridors are separated from use areas as requred. This deficiency could affect any patients, staff, or visitors in the area by compromising the protection offered by the egress corridors.

Findings include:

On October 19, 2016 at 2:03 PM, while accompanied by the DF, it was observed that Second Floor Interventional Radiology Office T2351, which is open to the adjacent Corridor via a pass-through window, lacks a smoke detector required by Subpart (c) of Exception 1 to 19.3.6.1.

Based on during the survey walk-through, the surveyor finds that not all doors in exit access corridors are resistant to the passage of smoke. These deficiencies could affect any patients, staff, or visitors in the immediate area by allowing smoke or fire to enter the egress corridor.

Findings include:

On October 18, 2016 at 10:15 AM , while accompanied by the FM it was observed that one of the double doors to the Information Suite (IS) on the 13th Floor, was not equipped with positive latching hardware. 19.3.6.3.2

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

Findings include:

A. On October 17, 2016 at 2:15 PM, while accompanied by the D, it was observed that the door to Basement Receiving Room TB142 is not positive latching, as required by 19.3.2.1 and 8.2.3.2.3.1(2), because the door hardware is damaged and not functioning.



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B. On October 18, 2016 at 2:30PM, while accompanied by the FM, it was observed that the door to the Storage Room T8056 near the Food Elevator on the 8th Floor, did not self-close to the latched position. This does not comply with NFPA 101, section 19.3.2.1.

C. On October 19, 2016 at 10:30 AM, while accompanied by the FM it was determined that Patient Room #736 on the 7th Floor is being used as a storage room and the door from the shared Toilet Room #736A was not installed with a self closing device. This does not comply with NFPA 101, section 19.3.2.1.

D. On October 19, 2016 at 11:20 AM, while accompanied by the FM it was determined that the door to the Laundry Closet for the Detox Unit on the 6th Floor was not installed with a self closing device. This does not comply with NFPA 101, section 19.3.2.1.

Based on observation during the survey walk-through and document review, 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 October 17, 2016 at 11:15 AM, while accompanied by the DF, it was determined at the review of the facility's Life Safety Master Plans, dated September 26, 2016, that a series of Exit Stair Shafts are identified as being of "non-rated/non-combustible" construction, and not of minimum 2 hour fire rated construction as required by 8.2.5.4(1). Exit Stairs for which this condition was indicated include:
A. The North Exit Stair.

B. The Northwest Exit Stair.

C. The Central Exit Stair.

D. The West Exit Stair.

E. The East Exit Stair.

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 October 18, 2016 at 10:45 AM, while accompanied by the DF, it was observed that the exterior exit door from First Floor Dining Room T1082, located immediately northeast of the East Exit Stair, was inoperable due to rust or other deleterious materials as prohibited by 7.2.1.5.1. The surveyor notes that this condition was corrected immediately.

B. On October 19, 2016 at 11:00 AM, while accompanied by the DF, it was observed a dead end Corridor of excessive length as prohibited by 19.2.5.10, extending from a locked pair of doors located immediately northwest of Third Floor Elevator 7 to a point in Corridor 3-063 immediately southwest of Third Floor Elevator 3.

C. On October 18, 2016 at 11:13 AM, while accompanied by the DF, it was observed a dead end Corridor of excessive length as prohibited by 19.2.5.10, extending from:

1. The Corridor door to First Floor Medical Director's Office T1242 to a point where First Floor Corridors T1033 and T1149 intersect.

2. The pair of Doors to the designated Emergency Department suite at the north end of First Floor Corridor T1228 to a point where First Floor Corridors T1033 and T1149 intersect.

D. On October 18, 2016 at 9:44 AM, while accompanied by the DF, it was observed that the door to Basement Storage Room TB076 (utilized as a satellite pharmacy) is equipped with a Dutch door which, because the upper leaf and the lower leaf each latch individually into the door frame, requires 2 operations to exit as prohibited by 7.2.1.5.4.



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E. On October 19, 2016 at 11:00 AM, while accompanied by the FM, it was observed that the 5th Floor exit access corridor T5064 near the Central Stair (T5056) by the three Service Elevators has one path of egress. This corridor terminates at the double doors of the ICU East Suite. Due to the lack of exit signage at the pair of cross corridor doors this condition creates a dead end corridor exceeding 30 feet which does not comply with 19.2.5.10.

F. On October 18, 2016 at 10:30 AM, while accompanied by the FM, it was observed on the 12th floor the designated path of egress for the North Wing (Smoke Zone A) to reach the North Exit Stair is directed through a hazardous area (Medical Library Suite). This does not comply with 7.5.2.1, 19.2.1 of NFPA 101 2000 Edition.

Based on observation during the survey walk-through, not all designated or required fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

A. On October 17, 2016 at 1:45 PM, while accompanied by the DF, it was observed pipe and other penetrations, through the designated 2 hour fire rated east wall of Basement Mechanical Room TB153, which are not sealed against the passage of fire as required by 8.2.3.2.4.2. Pipes not sealed include:
1. Medical gas pipes.

2. Sprinkler pipes.

B. On October 17, 2016, while accompanied by the DF, it was observed fire rated doors in designated fire rated partitions which are not self-closing as required by 8.2.3.2.3.1(1). Times observed and locations include (all Basement):

1. 2:26 PM: Electrical Closet TB131.

2. 2:27 PM: Electrical Closet TB132.

Based on observation during the survey walk through, the surveyor found that the fire alarm system and components are not installed properly. This could affect all occupants of the building if the fire alarm system does not operate properly during a fire emergency.

Findings include:

A. On October 18, 2016, at 10:20 AM, while accompanied by the FM, it was observed that in the 12th Floor Waiting Room, a smoke detector was located less than 3'-0 from an air supply diffuser. This does not comply with NFPA 101, Section 9.6 and NFPA 72-1999, 2-3.5.1.

B. On October 18, 2016, at 2:30 PM, while accompanied by the FM, it was observed that the smoke detector located in the 9th Floor, by the smoke barrier wall, near Room 925 was installed too close to a supply diffuser. This does not comply with NFPA 101, Section 9.6 and NFPA 72-1999, 2-3.5.1.

C. On October 19, 2016, at 9:00, AM, while accompanied by the FM it was determined by observations that on the 5th Floor, North Wing contained On-Call sleeping rooms each of the rooms were not installed with fire alarm strobe lights. This does not comply with NFPA 101, Section 19.3.4.1, Section 9.6 and NFPA 72, Section 4-4.4.3.

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 October 17, 2016 at 2:45 PM, while accompanied by the DF, it was observed that the sprinkler head in Basement Janitor's Closet TB125 was partially covered in tape as prohibited by NFPA 13 1999 2-4.1.8.

Based on observation during the survey walk-through, document review, and staff interview, not all portions of the facility's air conditioning and ventilating systems are installed and maintained in a compliant manner. These deficiencies could affect any patients, staff, or visitors in the building because smoke and fire could move between building stories.

Findings include:

A. On October 17, 2016 at 11:15 AM, while accompanied by the DF, the surveyor determined from the facility's Life Safety Master Plans, dated September 26, 2016, that a series of Ventilation and Pipe Shafts, all at least 4 stories in height, are identified as being of "non-rated/non-combustible" construction, and not of minimum 2 hour fire rated construction as required by NFPA 90A 1999 3-3.4.1. Ventilation and Pipe Shafts for which this condition was indicated include but are not limited to (where Room Numbers are shown, refer to First Floor):

1. Shafts at the west and south sides of the North Exit Stair.

2. Shafts at the east and west sides of the Northwest Exit Stair.

3. Shafts T1159 and T1225.

4. Shafts T1053, T1054, and T1055.
5. Shaft surrounding Elevators 3 and 4.

6. Shaft T1100.

7. Shafts immediately west of Elevator 7.

B. On October 18, 2016 at 1:00 PM, while accompanied by the DF, the surveyor determined from a Vendor's Report dated April 29, 2016, that a series of deficiencies related to the installation of fire dampers within the building had been discovered which render the devices out of compliance with NFPA 90A 1999 3-3.4.4. The DF confirmed at that time that the identified deficiencies with the fire damper installations had not yet been corrected.

C. On October 17, 2016 at 1:55 PM, while accompanied by the DF, the surveyor determined from the Life Safety Master Plans dated September 26, 2016 that the south wall of Basement Mechanical Room TB153, which is a part of a Ventilation Shaft which connects at least 4 building stories, does not carry a minimum 2 hour fire rating required by NFPA 90A 1999 3-3.4.1.



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D. On October 18, 2016, at 10:30 AM, while accompanied by the FM, it was observed that the duct penetration thru the ventilation shaft near the Equipment Room on the 11th Floor was observed equipped with a fire damper without a sleeve, which does not provide the proper rated UL tested assembly to comply with 8.2.3.2.4.1 and NFPA 90A 1999 3-3.1.1.

E. On October 18, 2016, at 2:10 PM, while accompanied by the FM, it was observed that the access door for the ventilation shaft located in the Center Stairwell between the 9th and the 10th Floor was not provided with self - closing hardware to comply with 8.2.3.2.1. (b).

F. On October 18, 2016 at 11:10 AM, while accompanied by the FM, it was observed that the ventilation shaft (T11065) on the 11th Floor - Center Core across the Nurse Station contained a duct penetration which lacked a damper installation. This does not comply with 8.2.3.2.4.

Based on observation during the survey walk-through, not all portable medical gases are stored in the required manner. This deficiency could affect any staff or visitors in the area because the the improperly stored gases could contribute to a fire

Findings include:

On October 17, 2016 at 2:45 PM, while accompanied by the DF, it was observed 5 gas tanks, in Basement Janitor's Closet TB125, which are not restrained as required by NFPA 99 1999 4-3.5.2.1.

Based on observation during the survey walk-through, not all medical gas piping systems are installed and maintained as required. These deficiencies could affect any patients in the cited area because the medical gas system could become compromised.

On October 17, 2016 at 2:38 PM, while accompanied by the DF, it was observed pipe and other penetrations, in Basement Oxygen Storage Room TB121, which are not sealed against the passage of fire as required by 8.2.3.2.4.2. and NFPA 99 1999 4-3.1.1.2. Unsealed penetrations (located above a non-fire rated ceiling assembly) observed include:
A. A series of openings in the east clay tile wall.
B. A cable tray in the south clay tile wall.

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 observation, the emergency power was not properly divided into three branches. This could effect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 10/18/16 at 9:25 AM, while accompanied by the RDSS, it was observed that critical panel 1WCP1, circuits 15, 27 and 29 were serving fire alarm loads. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-32.

Based on observation, the facility failed to provide a proper electrical system. This could effect any patient if a transfer switch failed.

Findings include:

On 10/17/16 between 2:15 PM and 315 PM, while accompanied by the RDSS, it was observed the following areas were not equipped with normal power receptacles or receptacles served from two separate critical transfer switches as required by the 1999 Edition of NFPA-99, Section 3-3.2.1.2(a)1.

A. The operating rooms

B. C-section rooms

C. ICU - East rooms