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Based on random observation during the survey walk-through, not all portions of the building are of a compliant construction type in accordance with 19.1.6.2. This deficiency could affect any patients, staff, or visitors in the building because a fire could spread from the lesser construction type to other portions of the building.

Findings include:
A. On the mooring of June 24, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the C Wing Mechanical Penthouse was observed to be of Type II (000) construction and to not be separated from the remainder of the Type I (332) construction as required by 8.2.1. because 3 floor penetrations by exhaust ducts lack fire dampers required by NFPA 90A 1999 3-3.4.1.

Based on random observation during the survey walk-through, not all wall and ceiling finishes in rooms or spaces could be verified as carrying a flame spread rating of Class A or B or less in accordance with 19.3.3.1. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke to develop in occupied portions of the building.

Findings include:

A. On the mooring of June 25, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, Masomite pegboard, which does not constitute a Class C finish, was observed mounted on the walls of Second Floor C Wing Clean Utility Room 139.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to enter the egress corridor.

Findings include:

A. On the afternoon of June 24, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the door to the Fourth Floor C Wing Locker Room immediately north of Exit Stair D was observed to not be positive latching as required by 19.3.6.3.2.

B. On the afternoon of June 24, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the hold-open feature at the automatic door operator at the north pair of doors to the Fifth Floor AB Wing Prep/Recovery Unit was observed to not release upon activation of the building fire alarm as required by 19.3.6.3.2.

Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 19.3.7.5., 19.3.7.6., and 19.3.7.7. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

A. On the afternoon of June 24, 2014,while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, doors were observed in smoke barrier walls that did not fully close upon activation of the building fire alarm as required by 19.3.7.6., because latching devices on the doors did not function properly and held the doors open. Locations observed include:

1. Fourth Floor C Wing cross-corridor doors in the smoke barrier wall adjacent to Exit Stair D.

2. Third Floor C Wing cross-corridor doors in the smoke barrier wall adjacent to Exit Stair D.

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. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. On the mooring of June 25, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, a series of vacant Patient Sleeping Rooms in the C Wing Second Floor (which is not covered by an automatic sprinkler system) were observed to be utilized for the storage of combustible materials, as prohibited by 19.3.2.1., because the walls of the rooms do not carry a minimum 1 hour fire rating, the doors do not carry a minimum 3/4 hour fire rating, and the doors are not self closing. Examples of vacant Patient Sleeping Rooms at which this condition was observed include but are not limited to:
1. Patient Sleeping Room 261.

2. Patient Sleeping Room 263.

3. Patient Sleeping Room 264.

4. Patient Sleeping Room 266.

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. On the mooring of June 24, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the spaces between guard rail elements at C Wing Exit Stair E were observed to be far enough apart that a 4" sphere could pass through them as prohibited by 7.2.2.4.6(3). Throughout the course of the survey, this condition was also observed to exist at:
1. AB Wing Exit Stair A.

2. AB Wing Exit Stair B.

3. AB Wing Exit Stair C.

4. C Wing Exit Stair D.

B. On the mooring of June 24, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the guard rails at all Exit Stairs cited in Item A. above were also observed to be less than 42" high as required by 7.2.2.4.6(2).

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect any patients, staff, or visitors in the area by preventing them from reaching an exit under fire conditions.

Findings include:

A. On the mooring of June 25, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the east door to AB Wing Elevator Lobby 253, which is in an identified egress path, was observed to not swing in the direction of egress as required by 7.2.1.4.2.

Based on random 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 the afternoon of June 24, 2014,while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the automatic door operators at the Second Floor pair of doors in the designated 2 hour fire barrier between the AB Wing and the ER/ICU Wing were observed to continue to operate after the activation of the building fire alarm system, as prohibited by 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

A. On the morning of June 25, 2014,while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, egress paths were observed that are not identified by exit signs as required by 7.10.1.1. Locations observed include:

1. First Floor of the AB Wing, the egress path toward the exterior exit door directly across from the ER/ICU Wing Waiting Room, because no exit sign exists in Corridor 125 which directs building occupants heading east toward the south.
2. Lower Level of the AB Wing:

a. The egress path toward the northeast door of the Dining Room, because no exit sigh exists adjacent to the angled wall which directs building occupants toward the northeast (the exit sign above the northeast door of the dining Room is not visible).

b. The egress path from the northwest Mechanical Room, because no exit sign exists at the south end of the Corridor serving the Mechanical Room which directs building occupants heading south toward the west and Exit Stair B.

Based on staff interview, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. This deficiency could affect any patients, staff, or visitors in the building because the staff may not be properly prepared for a fire emergency.

Findings include:

A. During an interview held in the Engineering Conference Room on the morning of June 25, 2014, the provider's Maintenance Technician confirmed that Third Shift fire drills do not include the transmission of a fire alarm signal as required by 19.7.1.2.

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke or fire to pass between building stories.

Findings include:

A. On the morning of June 25, 2014,while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, access panels at ventilation shafts which connect 4 or more building stories were observed to not carry a minimum 1-1/2 hour fire rating as required by 8.2.3.2.3.1(1) and NFPA 90A 1999 3-3.4.1. Locations observed include:

1. AB Wing Second Floor Mechaincal Room 4207, in north side of ventilation shaft directly north of Elevators.

2. C Wing Second Floor Mechanical Room 117, in ventilation shaft at north side of room.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. This deficiency could affect any patients, staff, or visitors in the area cited because they could be prevented from reaching exits.

Findings include:

A. On the afternoon of June 24, 2014,while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, carts, furnishings, gurneys, and equipment were observed in the Corridors of the Surgical Department that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1.

Based on random observation during the survey walk through the surveyor found that the generator installation did not meet all of the requirements of NFPA-110. This could affect all occupants of the building if the generator does not operate properly during a power outage.

Findings include:

A. The surveyor observed on the afternoon of 6/24/14 that the generators were not equipped with battery heaters as required by NFPA-110, Section 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 surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. The building was equipped with enough transfer switches for each branch of emergency power, but several of the panels served from the branch transfer switches were serving mixed loads and some of the transfer switches were serving panels from more than one branch as shown by some of the following examples:

1. The surveyor observed on the morning of 6/25/14 that critical panel 3CL1 on the 3rd floor, and panel BCL1 in the basement served elevator cab lighting which is required by Section 517-32 of NFPA-70 to be served from the life safety branch of emergency power.

2. The surveyor observed on the afternoon of 6/24/14 that panel EMPP in the elevator equipment room served a mixture of life safety, critical and equipment loads that are required by the 1999 edition of NFPA-70, Sections 517-30 through 517-35 to be separated into three separate branches.

3. The hospital staff was unable to locate life safety panels serving the loads required by NFPA-70, Section 517-32. They were not able to verify from the one-line diagram that there was a separate life safety transfer switch serving only life safety loads.

Based on random observation during the survey walk through the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70.

Findings include:

A. On the afternoon of 6/24/14 the surveyor observed that the cab lighting for the all elevators was not served from the life safety panel as required by NFPA-70, Section 517-32, and there was not a disconnect switch for cab lighting and controls within the elevator equipment room as required by NFPA-70, Section 620-22. This could affect any occupant of the building using the elevator during a power outage.

B. On the morning of 6/25/14, the surveyor observed that the C-section room was not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-18, and 517-19.

C. Panel identification and panel schedules are not accurate or have not been updated to meet the requirements of NFPA-70, Section 110-22, and Section 384-13.

D. On the morning of 6/25/14, the surveyor observed that the critical outlets in the C-section room and the Angio room were not labeled and identified in accordance with NFPA-70, Section 517-19.

Based on random observation during the survey walk through the surveyor found that the elevators did not meet all of the requirements of ANSI/ASME A17.3. This could affect any occupants of the facility using the elevator if proper safety equipment is not installed on each elevator.

Findings include:

A. The surveyor observed on the afternoon of 6/24/14 that the elevator machine room in the 1961 portion of the building did not have a heat detector within 2' of each 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).

B. The elevators machine rooms were not equipped with smoke detectors to initiate elevator recall in accordance with ANSI A17.1/A17.3.

Based on random observation during the survey walk-through, not all portions of the building are of a compliant construction type in accordance with 19.1.6.2. This deficiency could affect any patients, staff, or visitors in the building because a fire could spread from the lesser construction type to other portions of the building.

Findings include:
A. On the mooring of June 24, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the C Wing Mechanical Penthouse was observed to be of Type II (000) construction and to not be separated from the remainder of the Type I (332) construction as required by 8.2.1. because 3 floor penetrations by exhaust ducts lack fire dampers required by NFPA 90A 1999 3-3.4.1.

Based on random observation during the survey walk-through, not all wall and ceiling finishes in rooms or spaces could be verified as carrying a flame spread rating of Class A or B or less in accordance with 19.3.3.1. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke to develop in occupied portions of the building.

Findings include:

A. On the mooring of June 25, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, Masomite pegboard, which does not constitute a Class C finish, was observed mounted on the walls of Second Floor C Wing Clean Utility Room 139.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to enter the egress corridor.

Findings include:

A. On the afternoon of June 24, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the door to the Fourth Floor C Wing Locker Room immediately north of Exit Stair D was observed to not be positive latching as required by 19.3.6.3.2.

B. On the afternoon of June 24, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the hold-open feature at the automatic door operator at the north pair of doors to the Fifth Floor AB Wing Prep/Recovery Unit was observed to not release upon activation of the building fire alarm as required by 19.3.6.3.2.

Based on random observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke in accordance with 19.3.7.5., 19.3.7.6., and 19.3.7.7. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

A. On the afternoon of June 24, 2014,while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, doors were observed in smoke barrier walls that did not fully close upon activation of the building fire alarm as required by 19.3.7.6., because latching devices on the doors did not function properly and held the doors open. Locations observed include:

1. Fourth Floor C Wing cross-corridor doors in the smoke barrier wall adjacent to Exit Stair D.

2. Third Floor C Wing cross-corridor doors in the smoke barrier wall adjacent to Exit Stair D.

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. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. On the mooring of June 25, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, a series of vacant Patient Sleeping Rooms in the C Wing Second Floor (which is not covered by an automatic sprinkler system) were observed to be utilized for the storage of combustible materials, as prohibited by 19.3.2.1., because the walls of the rooms do not carry a minimum 1 hour fire rating, the doors do not carry a minimum 3/4 hour fire rating, and the doors are not self closing. Examples of vacant Patient Sleeping Rooms at which this condition was observed include but are not limited to:
1. Patient Sleeping Room 261.

2. Patient Sleeping Room 263.

3. Patient Sleeping Room 264.

4. Patient Sleeping Room 266.

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. On the mooring of June 24, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the spaces between guard rail elements at C Wing Exit Stair E were observed to be far enough apart that a 4" sphere could pass through them as prohibited by 7.2.2.4.6(3). Throughout the course of the survey, this condition was also observed to exist at:
1. AB Wing Exit Stair A.

2. AB Wing Exit Stair B.

3. AB Wing Exit Stair C.

4. C Wing Exit Stair D.

B. On the mooring of June 24, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the guard rails at all Exit Stairs cited in Item A. above were also observed to be less than 42" high as required by 7.2.2.4.6(2).

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect any patients, staff, or visitors in the area by preventing them from reaching an exit under fire conditions.

Findings include:

A. On the mooring of June 25, 2014, while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the east door to AB Wing Elevator Lobby 253, which is in an identified egress path, was observed to not swing in the direction of egress as required by 7.2.1.4.2.

Based on random 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 the afternoon of June 24, 2014,while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, the automatic door operators at the Second Floor pair of doors in the designated 2 hour fire barrier between the AB Wing and the ER/ICU Wing were observed to continue to operate after the activation of the building fire alarm system, as prohibited by 8.2.3.2.3.1(1).

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

A. On the morning of June 25, 2014,while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, egress paths were observed that are not identified by exit signs as required by 7.10.1.1. Locations observed include:

1. First Floor of the AB Wing, the egress path toward the exterior exit door directly across from the ER/ICU Wing Waiting Room, because no exit sign exists in Corridor 125 which directs building occupants heading east toward the south.
2. Lower Level of the AB Wing:

a. The egress path toward the northeast door of the Dining Room, because no exit sigh exists adjacent to the angled wall which directs building occupants toward the northeast (the exit sign above the northeast door of the dining Room is not visible).

b. The egress path from the northwest Mechanical Room, because no exit sign exists at the south end of the Corridor serving the Mechanical Room which directs building occupants heading south toward the west and Exit Stair B.

Based on staff interview, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. This deficiency could affect any patients, staff, or visitors in the building because the staff may not be properly prepared for a fire emergency.

Findings include:

A. During an interview held in the Engineering Conference Room on the morning of June 25, 2014, the provider's Maintenance Technician confirmed that Third Shift fire drills do not include the transmission of a fire alarm signal as required by 19.7.1.2.

Based on random observation during the survey walk-through, not all portions of the facility's air conditioning and ventilating systems are installed in accordance with NFPA 90A. These deficiencies could affect any patients, staff, or visitors in the building by permitting smoke or fire to pass between building stories.

Findings include:

A. On the morning of June 25, 2014,while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, access panels at ventilation shafts which connect 4 or more building stories were observed to not carry a minimum 1-1/2 hour fire rating as required by 8.2.3.2.3.1(1) and NFPA 90A 1999 3-3.4.1. Locations observed include:

1. AB Wing Second Floor Mechaincal Room 4207, in north side of ventilation shaft directly north of Elevators.

2. C Wing Second Floor Mechanical Room 117, in ventilation shaft at north side of room.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. This deficiency could affect any patients, staff, or visitors in the area cited because they could be prevented from reaching exits.

Findings include:

A. On the afternoon of June 24, 2014,while the surveyor was accompanied by the provider's Chief Operating Officer and a Maintenance Technician, carts, furnishings, gurneys, and equipment were observed in the Corridors of the Surgical Department that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1.

Based on random observation during the survey walk through the surveyor found that the generator installation did not meet all of the requirements of NFPA-110. This could affect all occupants of the building if the generator does not operate properly during a power outage.

Findings include:

A. The surveyor observed on the afternoon of 6/24/14 that the generators were not equipped with battery heaters as required by NFPA-110, Section 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 surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

A. The building was equipped with enough transfer switches for each branch of emergency power, but several of the panels served from the branch transfer switches were serving mixed loads and some of the transfer switches were serving panels from more than one branch as shown by some of the following examples:

1. The surveyor observed on the morning of 6/25/14 that critical panel 3CL1 on the 3rd floor, and panel BCL1 in the basement served elevator cab lighting which is required by Section 517-32 of NFPA-70 to be served from the life safety branch of emergency power.

2. The surveyor observed on the afternoon of 6/24/14 that panel EMPP in the elevator equipment room served a mixture of life safety, critical and equipment loads that are required by the 1999 edition of NFPA-70, Sections 517-30 through 517-35 to be separated into three separate branches.

3. The hospital staff was unable to locate life safety panels serving the loads required by NFPA-70, Section 517-32. They were not able to verify from the one-line diagram that there was a separate life safety transfer switch serving only life safety loads.

Based on random observation during the survey walk through the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70.

Findings include:

A. On the afternoon of 6/24/14 the surveyor observed that the cab lighting for the all elevators was not served from the life safety panel as required by NFPA-70, Section 517-32, and there was not a disconnect switch for cab lighting and controls within the elevator equipment room as required by NFPA-70, Section 620-22. This could affect any occupant of the building using the elevator during a power outage.

B. On the morning of 6/25/14, the surveyor observed that the C-section room was not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-18, and 517-19.

C. Panel identification and panel schedules are not accurate or have not been updated to meet the requirements of NFPA-70, Section 110-22, and Section 384-13.

D. On the morning of 6/25/14, the surveyor observed that the critical outlets in the C-section room and the Angio room were not labeled and identified in accordance with NFPA-70, Section 517-19.

Based on random observation during the survey walk through the surveyor found that the elevators did not meet all of the requirements of ANSI/ASME A17.3. This could affect any occupants of the facility using the elevator if proper safety equipment is not installed on each elevator.

Findings include:

A. The surveyor observed on the afternoon of 6/24/14 that the elevator machine room in the 1961 portion of the building did not have a heat detector within 2' of each 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).

B. The elevators machine rooms were not equipped with smoke detectors to initiate elevator recall in accordance with ANSI A17.1/A17.3.