HospitalInspections.org

Based on random observation during the survey walk-through, staff interview and review of Life Safety Plans produced by Shive-Hattery Architects in Moline, IL, the construction type of the building does not comply with NFPA 101 - 2000, 19.1.6.2. This deficiency could affect all in-patients in the facility, as well as those residents of the Long Term Care portion of the building and any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:
A. The original 1934 building area is partially sprinklered and indicated to be of Type III (000) construction type and is two stories with a basement. Although the floors are conrete construction, the columns and roof construction are unprotected or of wood frame construction which is not permitted under Table 19.1.6.2. Although the 2nd floor is provided with sprinkler protection, the wood frame roof is not separated from the rooms below due to holes in the original plaster ceiling above the suspended tile ceiling at the corridor and the conference room. Surveyor notes that the original building area is not otherwise separated from the Hospital by 2-hour rated construction on all floor levels to allow it to be classified as a separate non-healthcare occupancy building. The 2-hour separation is indicated to only exist on the 2nd floor.

B. The 1954 and 1974 building areas are indicated to be of Type II (000) construction type. These building areas are also two stories with a basement. The building construction type is not permitted under Table 19.1.6.2 without full sprinkler protection. The building areas are only partially sprinkler protected.

Based on observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.1. This deficiency could affect all patients in the locations 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. At 8:05am on 9/18/14 it was observed that the corridor door accessing the 2nd floor Pharmacy storage room was a push/pull door equipped with only a keyed dead bolt lock to provide latching. It could not be confirmed that egress from the room was always available because access to the room was not available at the time of observation.

Vertical openings between floors are not protected in compliance with 19.3.1.1 and 8.2.5. This deficiency could result in the effects of fire and smoke on one floor tranferring to another floor level compromising the safety of patients, staff and visitors during a fire/smoke event.

Findings include:
A. On 9/17/14 it was observed that there are unprotected vertical openings in floor systems which are not sealed in accordance with the minimum 1-hour fire resistance rated construction. Locations observed include but are not necessarily limited to the following:

1. At 2:40pm pipes and miscellaneous penetrations in the floor slab above observed in the Basement Maintenance Shop room.

2. At 2:55pm the medical vacuum system pipes and miscellaneous other plumbing pipes observed in the Basement Storage room containing the vacuum pump.

3. At 3:00pm miscellaneous plumbing pipes observed above the ceiling along the wall near the sink in the Basement level Autopsy room.

4. At 3:35pm a ventilation duct and abandoned pipe penetrations observed in the Basement level west wing Medical Gas Storage room. The duct was beleived to be a vent system when the room contained a manifold system (which no longer exists). The vent could not otherwise be confirmed to be enclosed in a shaft through the floors above.

B. At 10:35am on 9/18/14 it was observed that the 2nd floor door into the communicating stair could be opened fully to contact the stop on the floor and then not self-close to comply with 8.2.3.2.1.(b).

Based on random observation during the survey walk-through, not all designated or required smoke barrier doors are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Finding include:
A. At 10:00am on 9/18/14 it was observed that the cross corridor doors located in the West corridor of the Four Seasons Unit failed to close to a smoke tight position when the south door was opened after initially being closed. The coordinator and astragal arrangement does not permit the astragal-equipped door to open far enough to reset the coordinator function to allow the south door to always close first. However, the doors did function properly under automatic release and closing during fire alarm testing.

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 adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:
A. The entire basement area north and east of the main corridor between the Public Stair/elevator and the Family Care Clinic is considered a single hazardous area. At 3:20pm on 9/17/14 it was observed that the cross corridor doors at the north end of the main corridor are 1-hour labeled rated doors to comply with 19.3.2.1 but the inactive leaf is not equipped with a closer to meet the fire resistance label requirements. The inactive leaf can be left open.

B. At 8:40am on 9/18/14 it was observed that the 2nd floor south wing Clean Storage/Soiled/Clean Utility area is not separated from adjacent areas by 1-hour rated construction to comply with 19.3.2.1. The walls to adjacent areas contain windows and the doors are non-rated and have louvers. The corridor door is a newly installed rated asembly but the enclosing walls of the overall area are not full height. The Soiled and Clean Utility rooms accessed from the Clean Storage room are perforated metal pan ceilings which are not resistant to the passage of smoke if sprinkler protection is provided to comply with 19.3.2.1 and 8.4.1.

C. At 8:50am on 9/18/14 it was observed that the 2nd floor Linen Storage room (former Seclusion room) was not separated by 1-hour rated wall construction. The west wall observed above the ceiling contained unsealed/unprotected penetrations and/or damage.

D. At 3:50pm on 9/17/14 it was observed that the Family Care Clinic Soiled Workroom contained three 20+ gallon containers for trash, soiled linen hamper and recycling. The total capacity exceeded the 32 gallon capacity permitted under 19.7.5.5. The recently constructed sprinklered room was not otherwise enclosed as a hazardous area in accordance with 8.4.1.2 because the door was not self-closing.

Based on observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2.1.(a). These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by compromising the required protection of the exit enclosure and preventing those occupants from reaching an exit from the building.

Findings include:
A. At 9:35am on 9/18/14 it was observed that the fire rated door assembly from the Cafeteria to the ramp enclosure did not self-close to a lacthed condition to comply with 8.2.3.2.1.(b).

B. At 9:35am on 9/18/14 it was observed that the fire rated door assembly from the Kitchen to the ramp enclosure did not fully close to engage the bottom automatic flush bolt to securely latch the pair of doors. The flush bolt lacked a receiver at the floor and the doors appeared to be misalligned to prevent operation of the lower automatic flush bolt.

Based on observation during the survey walk-through, not all stairs are constructed and maintained in accordance with 19.2.2.3 and 7.2. These deficiencies could affect all persons required to utilize the exit components by preventing those occupants from safely reaching the public way from an exit from the building.

Findings include:
A. At 9:38am on 9/18/14 it was observed that the exterior stair from the 1934 building ramp exit discharge to the exterior stair has a bottom riser greater than 3/16" difference from the remaining risers of the stair in non-compliance with 7.2.2.3.6.

B. At 9:45am on 9/18/14 it was observed that the exterior stair at the exit stair serving the 1st floor Business Office has unequal riser heights greater than 3/16" difference in non-compliance with 7.2.2.3.6.

Based on observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:
A. Doors were observed to be provided with locking systems which could prevent egress. Conditions observed include:

1. At 8:50am on 9/18/14 it was observed that a double sided keyed dead bolt lock was installed on the 2nd floor Linen Storage room (former seclusion room) inner door in non-compliance with 7.2.1.5.1. The locking function is not compliant with the current use of the room.

2. At 10:00am on 9/18/14 it was observed that the Four Seasons Unit on the 1st floor had delayed egress magnetic locking devices installed on the exit doors of the unit (at the stairs and 2-hour barrier) which were reported to be non-functional at the time of the survey. It could not be determined whether the installation could comply with all requirements of 7.2.1.6.1. Therefore, removal of critical components to make clear that they are non-functional or compliance with all requirements of 7.2.1.6.1 is required.

3. At 3:55 on 9/17/14 it was observed that the doors at the vestibule for the exterior exit from the Basement Family Care Clinic were equipped with keyed dead bolt locks which can prevent egress.

B. Means of egress are obstructed to prevent the full instant use of the required path in non-compliance with 7.1.10.1. Conditions observed include:

1. At 9:40am on 9/18/14 it was observed that a window air conditioner unit serving the Lab area protruded over the handrail and stair to obstruct the full use of the handrail and normal path of egress on the exterior stair from the interior exit ramp serving the 1st and 2nd floors.

2. At 9:50am on 9/18/14 it was observed that a window air conditioner unit serving the Kitchen protruded over the sidewalk adjacent the building serving as the required path to the public way from the exit discharge of the Public Stair.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or 2-hour fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, because failure to construct and maintain fire resistive assemblies could allow fire and smoke to pass from one fire compartment into adjacent fire compartments.

Findings include:
A. The designated 2-hour barrier on the 2nd floor separating the 1934 building from the remainder of the building was observed to have a pair of fire rated doors equipped with panic hardware. One door was a vertical rod device, the other door was a non-functional rim device. The rim device equipped door did not provide latching hardware to comply with 8.2.3.2.1.(a) and NFPA 80.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress 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 identifying the path to an available exit from the building.

Findings include:
A. At 3:15pm on 9/17/14 it was observed that exit signage is not provided in the hall area south of the Maintenance Shop to identify two available exit routes. The cross corridor doors lack exit signage on the north side and the 'T' intersection at the south end of the north-south hall lacks directional signage.

Based on random observation during the survey walk-through, and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect any patients, staff, or visitors in the building because the failure to identify key life safety components could result in the failure to protect them properly.

Findings include:
A. On 9/17-18/14 and during the walk-through survey, a series of apparent errors were observed in the Life Safety Plans 10/15/10. These plans are thus not sufficiently accurate to comply with 19.7.1.1. Apparent errors include:

1. At 9:35am it was observed that the enclosure of the Ramp near the Kitchen is not accurately defined on the plan to indicate the 2-hour separation being at the wall & doors of the Kitchen and Dining room.

2. At 8:40am it was observed that hazardous areas such as the 2nd floor Soiled & Clean Utility rooms are noted to be enclosed with 1-hour rated construction, but lack 1-hour separation due to perforated ceiling systems, door hardware and non-full height walls.

3. At 3:20pm it was observed that the Basement level 1934/54 building areas are indicated to be individual rooms with 1-hour rated separations but numerous rooms lack proper doors, closers, latching hardware, etc. to be considered individually rather than within a single hazardous area suite.

4. Throughout the walk-through it was observed that areas to be considered suites in accordance with 18/19.2.5 are not identified on the plans. Areas which can comply as suites but would otherwise not comply as individual rooms due to arrangement of means of egress include the Basement Family Clinic area, the Physical Therapy area, and the 1934/54 building area considered to be a single hazardous area; the 1st floor Surgery area and the Radiology area; and the 2nd floor Specialty Clinic area and the 1934 building Office area.

Based on random observation during the survey walk through while accompanied by the Plant Operations Manager, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA 72-1999. This could affect all occupants of the Four Seasons Long Term Care Unit if the fire alarm system does not operate properly during a fire emergency.

Findings include:
A. At 10:45am on 9/18/14 it was observed that the Four Seasons Long Term Care Unit areas do not have audible fire alarm notification devices installed in accordance with NFPA 72-1999, 4-3.3.2. The conditions observed were a single buzzer device (and red indicator light) at the nurse station in the east smoke compartment and a single buzzer device (which could not be located) in the west smoke compartment. The buzzer devices could not be easily heard in all areas above ambient sound levels and could not be confirmed to be at least 10 dBA above the average ambient sound level to comply with 4-3.3.2.

Ventilation systems are not maintained in accordance with applicable standards.

Findings include:
A. At 2:00pm on 9/17/14 during review of the fire and smoke damper inspection documentation dated July 10/11, 2014 to comply with NFPA 90A, 1999, 3-4.7 there was no evidence to indicate deficiencies cited in the inspection have been corrected. A proposal for the work was received, but corrections are still pending.

B. At 3:35pm on 9/17/14 it was observed that the HVA/C system located in the Basement 'Kathabar' equipment room serving the 1974 building area was not installed and maintained in accordance with C222 - 42 CFR 486.623(b)(1) to ensure an acceptable level of safety and quality and C226 - 42 CFR 485.623(b)(5) to provide proper ventilation, light and temperature control for areas of the hospital. The air handling equipment is a 100% outside air system equipped with roll filters of unknown efficiency at the outside air intake. Upon inspection of the roll filter assembly on the down stream side of the filters it was observed that the duct space contained filtered debris intended to be retained by the filter system. However, the roll filter assembly operated in such a way as to filter the incoming air as intended but then as the filter rolled onto the spool mechanism it deposited the dirt/debris into the clean side of the filter assembly. The spooled filter media was not contained within enclosures to separated it from the air stream and/or reverse rolled to contain the dirty side of the filter within the roll. Thus not providing a minimum effective system to filter outside air in accordance with nationally recognized ASHRAE standards.

Based on random observation during the survey walk-through, not all piped-in medical gas systems are installed and maintained in accordance with NFPA 99-1999. Failure to install and/or maintain the medical gas system can result in failure of the system by accidental disruption of piping systems during maintenance operations.

Findings include:
A. At 9:10am on 9/18/14 it was observed that the piping believed to be a medical vacuum line at the 208 Roof Access Room was not labeled in accordance with NFPA 99-1999, 4-3.1.2.13 and 4-3.1.2.14. Labeling was not provided on both sides of the partition penetrated, at least once in each room, and at intervals not exceeding 20 ft.

The Hospital generator system is not in compliance with NFPA 99-1999, 3-4.1.1.13 and NFPA 110-1999, 3-1.1 and 5-9.7.

Findings include:
A. The natural gas fuel supply for the generator is installed in accordance with NFPA 110-1999, 5-9.7 but is not properly labeled. The fuel supply for the generator is connected ahead of the building's main shut-off valve but is not marked as supplying an emergency generator. The building's main gas shut-off valve is not marked or tagged to indicate the existance of a separate Emergency Power Supply shut-off valve.

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, not all portions of the facility's electrical distribution system are in accordance with NFPA 70-1999.

Findings include:
A. At 2:40pm on 9/17/14 it was observed that the "X5" panel noted to be an essential electrical system emergency power supply panel contained non-essential load circuits and no separation of the three required branches of Critical, Life Safety and Equipment branches in accordance with 517-30 (b).

Based on random observation during the survey walk-through, staff interview and review of Life Safety Plans produced by Shive-Hattery Architects in Moline, IL, the construction type of the building does not comply with NFPA 101 - 2000, 19.1.6.2. This deficiency could affect all in-patients in the facility, as well as those residents of the Long Term Care portion of the building and any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:
A. The original 1934 building area is partially sprinklered and indicated to be of Type III (000) construction type and is two stories with a basement. Although the floors are conrete construction, the columns and roof construction are unprotected or of wood frame construction which is not permitted under Table 19.1.6.2. Although the 2nd floor is provided with sprinkler protection, the wood frame roof is not separated from the rooms below due to holes in the original plaster ceiling above the suspended tile ceiling at the corridor and the conference room. Surveyor notes that the original building area is not otherwise separated from the Hospital by 2-hour rated construction on all floor levels to allow it to be classified as a separate non-healthcare occupancy building. The 2-hour separation is indicated to only exist on the 2nd floor.

B. The 1954 and 1974 building areas are indicated to be of Type II (000) construction type. These building areas are also two stories with a basement. The building construction type is not permitted under Table 19.1.6.2 without full sprinkler protection. The building areas are only partially sprinkler protected.

Based on observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.1. This deficiency could affect all patients in the locations 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. At 8:05am on 9/18/14 it was observed that the corridor door accessing the 2nd floor Pharmacy storage room was a push/pull door equipped with only a keyed dead bolt lock to provide latching. It could not be confirmed that egress from the room was always available because access to the room was not available at the time of observation.

Vertical openings between floors are not protected in compliance with 19.3.1.1 and 8.2.5. This deficiency could result in the effects of fire and smoke on one floor tranferring to another floor level compromising the safety of patients, staff and visitors during a fire/smoke event.

Findings include:
A. On 9/17/14 it was observed that there are unprotected vertical openings in floor systems which are not sealed in accordance with the minimum 1-hour fire resistance rated construction. Locations observed include but are not necessarily limited to the following:

1. At 2:40pm pipes and miscellaneous penetrations in the floor slab above observed in the Basement Maintenance Shop room.

2. At 2:55pm the medical vacuum system pipes and miscellaneous other plumbing pipes observed in the Basement Storage room containing the vacuum pump.

3. At 3:00pm miscellaneous plumbing pipes observed above the ceiling along the wall near the sink in the Basement level Autopsy room.

4. At 3:35pm a ventilation duct and abandoned pipe penetrations observed in the Basement level west wing Medical Gas Storage room. The duct was beleived to be a vent system when the room contained a manifold system (which no longer exists). The vent could not otherwise be confirmed to be enclosed in a shaft through the floors above.

B. At 10:35am on 9/18/14 it was observed that the 2nd floor door into the communicating stair could be opened fully to contact the stop on the floor and then not self-close to comply with 8.2.3.2.1.(b).

Based on random observation during the survey walk-through, not all designated or required smoke barrier doors are constructed or maintained as minimum 30 minute fire rated assemblies in accordance with 19.3.7.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Finding include:
A. At 10:00am on 9/18/14 it was observed that the cross corridor doors located in the West corridor of the Four Seasons Unit failed to close to a smoke tight position when the south door was opened after initially being closed. The coordinator and astragal arrangement does not permit the astragal-equipped door to open far enough to reset the coordinator function to allow the south door to always close first. However, the doors did function properly under automatic release and closing during fire alarm testing.

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 adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:
A. The entire basement area north and east of the main corridor between the Public Stair/elevator and the Family Care Clinic is considered a single hazardous area. At 3:20pm on 9/17/14 it was observed that the cross corridor doors at the north end of the main corridor are 1-hour labeled rated doors to comply with 19.3.2.1 but the inactive leaf is not equipped with a closer to meet the fire resistance label requirements. The inactive leaf can be left open.

B. At 8:40am on 9/18/14 it was observed that the 2nd floor south wing Clean Storage/Soiled/Clean Utility area is not separated from adjacent areas by 1-hour rated construction to comply with 19.3.2.1. The walls to adjacent areas contain windows and the doors are non-rated and have louvers. The corridor door is a newly installed rated asembly but the enclosing walls of the overall area are not full height. The Soiled and Clean Utility rooms accessed from the Clean Storage room are perforated metal pan ceilings which are not resistant to the passage of smoke if sprinkler protection is provided to comply with 19.3.2.1 and 8.4.1.

C. At 8:50am on 9/18/14 it was observed that the 2nd floor Linen Storage room (former Seclusion room) was not separated by 1-hour rated wall construction. The west wall observed above the ceiling contained unsealed/unprotected penetrations and/or damage.

D. At 3:50pm on 9/17/14 it was observed that the Family Care Clinic Soiled Workroom contained three 20+ gallon containers for trash, soiled linen hamper and recycling. The total capacity exceeded the 32 gallon capacity permitted under 19.7.5.5. The recently constructed sprinklered room was not otherwise enclosed as a hazardous area in accordance with 8.4.1.2 because the door was not self-closing.

Based on observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2.1.(a). These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by compromising the required protection of the exit enclosure and preventing those occupants from reaching an exit from the building.

Findings include:
A. At 9:35am on 9/18/14 it was observed that the fire rated door assembly from the Cafeteria to the ramp enclosure did not self-close to a lacthed condition to comply with 8.2.3.2.1.(b).

B. At 9:35am on 9/18/14 it was observed that the fire rated door assembly from the Kitchen to the ramp enclosure did not fully close to engage the bottom automatic flush bolt to securely latch the pair of doors. The flush bolt lacked a receiver at the floor and the doors appeared to be misalligned to prevent operation of the lower automatic flush bolt.

Based on observation during the survey walk-through, not all stairs are constructed and maintained in accordance with 19.2.2.3 and 7.2. These deficiencies could affect all persons required to utilize the exit components by preventing those occupants from safely reaching the public way from an exit from the building.

Findings include:
A. At 9:38am on 9/18/14 it was observed that the exterior stair from the 1934 building ramp exit discharge to the exterior stair has a bottom riser greater than 3/16" difference from the remaining risers of the stair in non-compliance with 7.2.2.3.6.

B. At 9:45am on 9/18/14 it was observed that the exterior stair at the exit stair serving the 1st floor Business Office has unequal riser heights greater than 3/16" difference in non-compliance with 7.2.2.3.6.

Based on observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:
A. Doors were observed to be provided with locking systems which could prevent egress. Conditions observed include:

1. At 8:50am on 9/18/14 it was observed that a double sided keyed dead bolt lock was installed on the 2nd floor Linen Storage room (former seclusion room) inner door in non-compliance with 7.2.1.5.1. The locking function is not compliant with the current use of the room.

2. At 10:00am on 9/18/14 it was observed that the Four Seasons Unit on the 1st floor had delayed egress magnetic locking devices installed on the exit doors of the unit (at the stairs and 2-hour barrier) which were reported to be non-functional at the time of the survey. It could not be determined whether the installation could comply with all requirements of 7.2.1.6.1. Therefore, removal of critical components to make clear that they are non-functional or compliance with all requirements of 7.2.1.6.1 is required.

3. At 3:55 on 9/17/14 it was observed that the doors at the vestibule for the exterior exit from the Basement Family Care Clinic were equipped with keyed dead bolt locks which can prevent egress.

B. Means of egress are obstructed to prevent the full instant use of the required path in non-compliance with 7.1.10.1. Conditions observed include:

1. At 9:40am on 9/18/14 it was observed that a window air conditioner unit serving the Lab area protruded over the handrail and stair to obstruct the full use of the handrail and normal path of egress on the exterior stair from the interior exit ramp serving the 1st and 2nd floors.

2. At 9:50am on 9/18/14 it was observed that a window air conditioner unit serving the Kitchen protruded over the sidewalk adjacent the building serving as the required path to the public way from the exit discharge of the Public Stair.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or 2-hour fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, because failure to construct and maintain fire resistive assemblies could allow fire and smoke to pass from one fire compartment into adjacent fire compartments.

Findings include:
A. The designated 2-hour barrier on the 2nd floor separating the 1934 building from the remainder of the building was observed to have a pair of fire rated doors equipped with panic hardware. One door was a vertical rod device, the other door was a non-functional rim device. The rim device equipped door did not provide latching hardware to comply with 8.2.3.2.1.(a) and NFPA 80.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress 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 identifying the path to an available exit from the building.

Findings include:
A. At 3:15pm on 9/17/14 it was observed that exit signage is not provided in the hall area south of the Maintenance Shop to identify two available exit routes. The cross corridor doors lack exit signage on the north side and the 'T' intersection at the south end of the north-south hall lacks directional signage.

Based on random observation during the survey walk-through, and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect any patients, staff, or visitors in the building because the failure to identify key life safety components could result in the failure to protect them properly.

Findings include:
A. On 9/17-18/14 and during the walk-through survey, a series of apparent errors were observed in the Life Safety Plans 10/15/10. These plans are thus not sufficiently accurate to comply with 19.7.1.1. Apparent errors include:

1. At 9:35am it was observed that the enclosure of the Ramp near the Kitchen is not accurately defined on the plan to indicate the 2-hour separation being at the wall & doors of the Kitchen and Dining room.

2. At 8:40am it was observed that hazardous areas such as the 2nd floor Soiled & Clean Utility rooms are noted to be enclosed with 1-hour rated construction, but lack 1-hour separation due to perforated ceiling systems, door hardware and non-full height walls.

3. At 3:20pm it was observed that the Basement level 1934/54 building areas are indicated to be individual rooms with 1-hour rated separations but numerous rooms lack proper doors, closers, latching hardware, etc. to be considered individually rather than within a single hazardous area suite.

4. Throughout the walk-through it was observed that areas to be considered suites in accordance with 18/19.2.5 are not identified on the plans. Areas which can comply as suites but would otherwise not comply as individual rooms due to arrangement of means of egress include the Basement Family Clinic area, the Physical Therapy area, and the 1934/54 building area considered to be a single hazardous area; the 1st floor Surgery area and the Radiology area; and the 2nd floor Specialty Clinic area and the 1934 building Office area.

Based on random observation during the survey walk through while accompanied by the Plant Operations Manager, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA 72-1999. This could affect all occupants of the Four Seasons Long Term Care Unit if the fire alarm system does not operate properly during a fire emergency.

Findings include:
A. At 10:45am on 9/18/14 it was observed that the Four Seasons Long Term Care Unit areas do not have audible fire alarm notification devices installed in accordance with NFPA 72-1999, 4-3.3.2. The conditions observed were a single buzzer device (and red indicator light) at the nurse station in the east smoke compartment and a single buzzer device (which could not be located) in the west smoke compartment. The buzzer devices could not be easily heard in all areas above ambient sound levels and could not be confirmed to be at least 10 dBA above the average ambient sound level to comply with 4-3.3.2.

Ventilation systems are not maintained in accordance with applicable standards.

Findings include:
A. At 2:00pm on 9/17/14 during review of the fire and smoke damper inspection documentation dated July 10/11, 2014 to comply with NFPA 90A, 1999, 3-4.7 there was no evidence to indicate deficiencies cited in the inspection have been corrected. A proposal for the work was received, but corrections are still pending.

B. At 3:35pm on 9/17/14 it was observed that the HVA/C system located in the Basement 'Kathabar' equipment room serving the 1974 building area was not installed and maintained in accordance with C222 - 42 CFR 486.623(b)(1) to ensure an acceptable level of safety and quality and C226 - 42 CFR 485.623(b)(5) to provide proper ventilation, light and temperature control for areas of the hospital. The air handling equipment is a 100% outside air system equipped with roll filters of unknown efficiency at the outside air intake. Upon inspection of the roll filter assembly on the down stream side of the filters it was observed that the duct space contained filtered debris intended to be retained by the filter system. However, the roll filter assembly operated in such a way as to filter the incoming air as intended but then as the filter rolled onto the spool mechanism it deposited the dirt/debris into the clean side of the filter assembly. The spooled filter media was not contained within enclosures to separated it from the air stream and/or reverse rolled to contain the dirty side of the filter within the roll. Thus not providing a minimum effective system to filter outside air in accordance with nationally recognized ASHRAE standards.

Based on random observation during the survey walk-through, not all piped-in medical gas systems are installed and maintained in accordance with NFPA 99-1999. Failure to install and/or maintain the medical gas system can result in failure of the system by accidental disruption of piping systems during maintenance operations.

Findings include:
A. At 9:10am on 9/18/14 it was observed that the piping believed to be a medical vacuum line at the 208 Roof Access Room was not labeled in accordance with NFPA 99-1999, 4-3.1.2.13 and 4-3.1.2.14. Labeling was not provided on both sides of the partition penetrated, at least once in each room, and at intervals not exceeding 20 ft.

The Hospital generator system is not in compliance with NFPA 99-1999, 3-4.1.1.13 and NFPA 110-1999, 3-1.1 and 5-9.7.

Findings include:
A. The natural gas fuel supply for the generator is installed in accordance with NFPA 110-1999, 5-9.7 but is not properly labeled. The fuel supply for the generator is connected ahead of the building's main shut-off valve but is not marked as supplying an emergency generator. The building's main gas shut-off valve is not marked or tagged to indicate the existance of a separate Emergency Power Supply shut-off valve.

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, not all portions of the facility's electrical distribution system are in accordance with NFPA 70-1999.

Findings include:
A. At 2:40pm on 9/17/14 it was observed that the "X5" panel noted to be an essential electrical system emergency power supply panel contained non-essential load circuits and no separation of the three required branches of Critical, Life Safety and Equipment branches in accordance with 517-30 (b).