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Based on a direct observation the facility failed to provide properly rated fire-resistance fire barrier doors. This deficient practice could affect patents, staff and visitors if a fire was allowed to spread into the facility from an adjacent nonconforming building.

Findings include:

On 04/08/2015 at 11:05 AM, while accompanied by the Plant Operations Manager, it was determined by observation on the first floor, the designated 2-hour separation wall between the business occupancy and the hospital health care occupancy contained 2 doors that were deficient.

1. West door from clinic waiting room did not contain a 1 1/2-hour rated label.

2. South door from Northwest Clinic Suite 110 contained 4 holes in the 1 ½-hour rated door.

3. South door frame from Northwest Clinic Suite 110 contained 2 holes in the 1 ½-hour rated frame.

This is not per NFPA 101, Section 8.2 and 18.1.2.3 and 7.2.1.7, NFPA 80 1999 Edition Fire Doors and Windows.

Based on direct observations during the survey walk-though it was determined that the facility failed to properly enclose shafts and chases. This deficient practice could affect patients, staff and visitor if smoke and fire were to travel throughout the tunnel system and migrate into the building.

Findings include:

On 04/07/2015 at 9:50 AM, while accompanied by the Plant Operations Manager, it was determined by observation, the second floor mechanical room #6 contained a vertical shaft that is open to the underground tunnel system and not sealed off with proper fire rated materials. This does not comply with NFPA 101, section 18.3.1.1.

Based on direct observations and interview of the placement of exit fixtures, it was determined that the facility has not provided approved directional emergency illuminated exit signs readily visible from any direction of exit access where the nearest exit is not apparent. This deficient practice could affect patients, staff and visitors if an evacuation of the building was required and exit paths are not clearly marked.

Findings include:

A. On 04/07/2015 at 12:47 PM, while accompanied by the Plant Operations Manager, it was determined by observation, the first floor corridor adjacent to the seating area outside of the skilled nursing unit did not contain a directional " EXIT " sign. This does not comply with NFPA 101, section 7.10.1.4.

B. On 04/07/2015 at 1:29 PM, while accompanied by the Plant Operations Manager, it was determined by observation, the second floor corridor leading to physical therapy did not contain a directional " EXIT " sign at the intersection of the corridor. This does not comply with NFPA 101, section 7.10.1.4.

C. On 04/07/2015 at 1:47 PM, while accompanied by the Plant Operations Manager, it was determined by observation, the second floor Physical Therapy Unit outside terrace contains 3 doors leading back into the unit. At least one door needs to be identified with an exterior " EXIT " sign. This does not comply with NFPA 101, section 7.10.1.4.

Based on direct observations and an interview the facility failed to provide proper exit door hardware. This deficient practice could affect patients, staff and visitors if door hardware prevented timely exiting from a compartment of fire origin.

Findings include:

A. On 04/07/2015 at 1:47 PM, while accompanied by the Plant Operations Manager it was determined by an observation that on the second floor, physical therapy unit contained an outside terrace with 3 doors leading back into the unit. The doors when tested were locked from reentry back into the building. Further observations determined that no addition exiting was provided from this second floor roof terrace to grade. This does not comply with NFPA 101, section 18.2.2.2.4.

B. On 04/07/2015 at 3:00 PM, while accompanied by the Plant Operations Manager, it was determined by observation, the first floor MRI waiting area contained an exit door to the exterior and was installed with a deadbolt. This does not comply with NFPA 101, section 18.2. and section 7.2.1.5.4.

C. On 04/08/2015 at 9:42 AM, while accompanied by the Plant Operations Manager, it was determined by observation, the first floor Cafeteria, food serving area contained 2 openings that were installed with electrically controlled coiling doors with a manual override lever. The coiling doors are not tied into the emergency generator and upon power loss would require manual operation and cause a delay in exiting if needed. The 2 doors were installed with " EXIT " signs directing visitors out of this area. This does not comply with NFPA 101, section 18.2. and section 7.2.1.5.4.

D. On 04/08/2015 at 9:10 AM, while accompanied by the Plant Operations Manager. it was determined by observation, the second floor surgery double doors adjacent to the women ' s dressing Room 228 failed to release from the electronic magnetic locking system when the fire alarm system was tested. This does not comply with NFPA 101, section 18.2. and section 7.2.1.6.2 (b).

Based on direct observations made during the survey walk through it was determined that the fire alarm system installation was deficient. This deficiency could affect patients, staff and visitor if the fire alarm system failed to operate during a fire emergency.

Findings include:

A. On 04/07/2015 at 10:45 AM, while accompanied by the Plant Operations Manager, the surveyor observed the fire alarm panel located in the maintenance shop which was not staffed 24 hours was not equipped with a smoke detector as required by NFPA-72, Section 1-5.6.

B. On 04/07/2015 at 3:15 PM, while accompanied by the Plant Operations Manager, it was determined elevator #1 was not equipped with a heat detector within 2-feet of the sprinkler head tied to a shunt trip as required by NFPA-72, Section 3-9.4, and ASME A17.1, Section 102.2(c)(3).

Based on direct observation, the facility failed to have a complete sprinkler system installed. This deficient practice could affect patients, staff and visitors if a sprinkler system was not available during a fire emergency.

Findings include:

A. On 04/07/2015 at 3:05 PM, while accompanied by the Plant Operations Manager, it was determined by observation,the first floor MRI waiting room, control room and MRI room were not installed with a sprinkler system. This area of the facility was renovated in 2010 and was not updated to meet new construction requirements. This does not comply with NFPA 101, section 18.1.1.4.5.

B. On 04/08/2015 at 10:34 AM, while accompanied by the Plant Operations Manager, it was determined by observation, the first floor Lab area contained 2 rooms that were not sprinkler protected. The technician work room and the micro-biology lab were not installed with a sprinkler heads. This area of the facility was renovated in 2010 and was not updated to meet new construction requirements. This does not comply with NFPA 101, section 18.1.1.4.5.

Based on a direct observation made during the survey walk through the generator installation did not meet all of the requirements. This could affect patients, staff and visitors if the generator does not operate properly during a power outage.

Findings include:

On 04/07/2015 at 11:15 AM, while accompanied by the Plant Operations Manager, it was determined by observation that the generator battery was not equipped with a battery heater to meet the requirements of NFPA-110, Section 3-3.1.

Based on direct observations made during the survey walk through it was determined that the emergency electrical installation did not meet all of the requirements. This deficient practice could affect patients, staff and visitors if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. On 04/07/2015 at 1:30 PM, while accompanied by the Plant Operations Manager, the surveyor observed that the critical panel CCRMM2 was feeding elevator #3 cab lighting and a NAC panel. NFPA-70, Section 517-32 requires elevator cab lighting and fire alarm equipment to be served from the life safety panel.

B. On 04/08/2015, at 10:00 AM, while accompanied by the Plant Operations Manager, the surveyor observed that life safety panel L11 had circuit breakers serving loads other than those allowed by NFPA-70, Section 517-32, including a three pole circuit breaker serving XRAY equipment.

Based on direct observations made during the survey walk through while accompanied by the Plant Operations Manager, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

A. On 04/07/2015, at 2:45 PM, while accompanied by the Plant Operations Manager, the surveyor observed that ER rooms 5 through 10 were not equipped with critical receptacles in accordance with NFPA-70, Section 517-33.

B. On 04/07/2015, at 3:15 PM, while accompanied by the Plant Operations Manager, the surveyor observed that the lighting disconnect for elevator #1 was not labeled in accordance with NFPA-70, Section 620-53.

C. On 04/08/2015 at 10:30 AM, while accompanied by the Plant Operations Manager, the surveyor observed that elevator #4 was not equipped with a lighting disconnect in the elevator equipment room in accordance with NFPA-70, Section 620-53.

Based on a direct observation the facility failed to provide properly rated fire-resistance fire barrier doors. This deficient practice could affect patents, staff and visitors if a fire was allowed to spread into the facility from an adjacent nonconforming building.

Findings include:

On 04/08/2015 at 11:05 AM, while accompanied by the Plant Operations Manager, it was determined by observation on the first floor, the designated 2-hour separation wall between the business occupancy and the hospital health care occupancy contained 2 doors that were deficient.

1. West door from clinic waiting room did not contain a 1 1/2-hour rated label.

2. South door from Northwest Clinic Suite 110 contained 4 holes in the 1 ½-hour rated door.

3. South door frame from Northwest Clinic Suite 110 contained 2 holes in the 1 ½-hour rated frame.

This is not per NFPA 101, Section 8.2 and 18.1.2.3 and 7.2.1.7, NFPA 80 1999 Edition Fire Doors and Windows.

Based on direct observations during the survey walk-though it was determined that the facility failed to properly enclose shafts and chases. This deficient practice could affect patients, staff and visitor if smoke and fire were to travel throughout the tunnel system and migrate into the building.

Findings include:

On 04/07/2015 at 9:50 AM, while accompanied by the Plant Operations Manager, it was determined by observation, the second floor mechanical room #6 contained a vertical shaft that is open to the underground tunnel system and not sealed off with proper fire rated materials. This does not comply with NFPA 101, section 18.3.1.1.

Based on direct observations and interview of the placement of exit fixtures, it was determined that the facility has not provided approved directional emergency illuminated exit signs readily visible from any direction of exit access where the nearest exit is not apparent. This deficient practice could affect patients, staff and visitors if an evacuation of the building was required and exit paths are not clearly marked.

Findings include:

A. On 04/07/2015 at 12:47 PM, while accompanied by the Plant Operations Manager, it was determined by observation, the first floor corridor adjacent to the seating area outside of the skilled nursing unit did not contain a directional " EXIT " sign. This does not comply with NFPA 101, section 7.10.1.4.

B. On 04/07/2015 at 1:29 PM, while accompanied by the Plant Operations Manager, it was determined by observation, the second floor corridor leading to physical therapy did not contain a directional " EXIT " sign at the intersection of the corridor. This does not comply with NFPA 101, section 7.10.1.4.

C. On 04/07/2015 at 1:47 PM, while accompanied by the Plant Operations Manager, it was determined by observation, the second floor Physical Therapy Unit outside terrace contains 3 doors leading back into the unit. At least one door needs to be identified with an exterior " EXIT " sign. This does not comply with NFPA 101, section 7.10.1.4.

Based on direct observations and an interview the facility failed to provide proper exit door hardware. This deficient practice could affect patients, staff and visitors if door hardware prevented timely exiting from a compartment of fire origin.

Findings include:

A. On 04/07/2015 at 1:47 PM, while accompanied by the Plant Operations Manager it was determined by an observation that on the second floor, physical therapy unit contained an outside terrace with 3 doors leading back into the unit. The doors when tested were locked from reentry back into the building. Further observations determined that no addition exiting was provided from this second floor roof terrace to grade. This does not comply with NFPA 101, section 18.2.2.2.4.

B. On 04/07/2015 at 3:00 PM, while accompanied by the Plant Operations Manager, it was determined by observation, the first floor MRI waiting area contained an exit door to the exterior and was installed with a deadbolt. This does not comply with NFPA 101, section 18.2. and section 7.2.1.5.4.

C. On 04/08/2015 at 9:42 AM, while accompanied by the Plant Operations Manager, it was determined by observation, the first floor Cafeteria, food serving area contained 2 openings that were installed with electrically controlled coiling doors with a manual override lever. The coiling doors are not tied into the emergency generator and upon power loss would require manual operation and cause a delay in exiting if needed. The 2 doors were installed with " EXIT " signs directing visitors out of this area. This does not comply with NFPA 101, section 18.2. and section 7.2.1.5.4.

D. On 04/08/2015 at 9:10 AM, while accompanied by the Plant Operations Manager. it was determined by observation, the second floor surgery double doors adjacent to the women ' s dressing Room 228 failed to release from the electronic magnetic locking system when the fire alarm system was tested. This does not comply with NFPA 101, section 18.2. and section 7.2.1.6.2 (b).

Based on direct observations made during the survey walk through it was determined that the fire alarm system installation was deficient. This deficiency could affect patients, staff and visitor if the fire alarm system failed to operate during a fire emergency.

Findings include:

A. On 04/07/2015 at 10:45 AM, while accompanied by the Plant Operations Manager, the surveyor observed the fire alarm panel located in the maintenance shop which was not staffed 24 hours was not equipped with a smoke detector as required by NFPA-72, Section 1-5.6.

B. On 04/07/2015 at 3:15 PM, while accompanied by the Plant Operations Manager, it was determined elevator #1 was not equipped with a heat detector within 2-feet of the sprinkler head tied to a shunt trip as required by NFPA-72, Section 3-9.4, and ASME A17.1, Section 102.2(c)(3).

Based on direct observation, the facility failed to have a complete sprinkler system installed. This deficient practice could affect patients, staff and visitors if a sprinkler system was not available during a fire emergency.

Findings include:

A. On 04/07/2015 at 3:05 PM, while accompanied by the Plant Operations Manager, it was determined by observation,the first floor MRI waiting room, control room and MRI room were not installed with a sprinkler system. This area of the facility was renovated in 2010 and was not updated to meet new construction requirements. This does not comply with NFPA 101, section 18.1.1.4.5.

B. On 04/08/2015 at 10:34 AM, while accompanied by the Plant Operations Manager, it was determined by observation, the first floor Lab area contained 2 rooms that were not sprinkler protected. The technician work room and the micro-biology lab were not installed with a sprinkler heads. This area of the facility was renovated in 2010 and was not updated to meet new construction requirements. This does not comply with NFPA 101, section 18.1.1.4.5.

Based on a direct observation made during the survey walk through the generator installation did not meet all of the requirements. This could affect patients, staff and visitors if the generator does not operate properly during a power outage.

Findings include:

On 04/07/2015 at 11:15 AM, while accompanied by the Plant Operations Manager, it was determined by observation that the generator battery was not equipped with a battery heater to meet the requirements of NFPA-110, Section 3-3.1.

Based on direct observations made during the survey walk through it was determined that the emergency electrical installation did not meet all of the requirements. This deficient practice could affect patients, staff and visitors if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. On 04/07/2015 at 1:30 PM, while accompanied by the Plant Operations Manager, the surveyor observed that the critical panel CCRMM2 was feeding elevator #3 cab lighting and a NAC panel. NFPA-70, Section 517-32 requires elevator cab lighting and fire alarm equipment to be served from the life safety panel.

B. On 04/08/2015, at 10:00 AM, while accompanied by the Plant Operations Manager, the surveyor observed that life safety panel L11 had circuit breakers serving loads other than those allowed by NFPA-70, Section 517-32, including a three pole circuit breaker serving XRAY equipment.

Based on direct observations made during the survey walk through while accompanied by the Plant Operations Manager, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

A. On 04/07/2015, at 2:45 PM, while accompanied by the Plant Operations Manager, the surveyor observed that ER rooms 5 through 10 were not equipped with critical receptacles in accordance with NFPA-70, Section 517-33.

B. On 04/07/2015, at 3:15 PM, while accompanied by the Plant Operations Manager, the surveyor observed that the lighting disconnect for elevator #1 was not labeled in accordance with NFPA-70, Section 620-53.

C. On 04/08/2015 at 10:30 AM, while accompanied by the Plant Operations Manager, the surveyor observed that elevator #4 was not equipped with a lighting disconnect in the elevator equipment room in accordance with NFPA-70, Section 620-53.