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Based on random observation during the survey walk-through and staff interview, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. 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:

A. During an interview held in the Conference Room at 10:45 AM on February 18, 2014, the provider's Architectural Consultant stated that the building (including the Hospital and the X-Ray Addition) is of Type II (000) construction; the building is not fully covered by an automatic sprinkler system as required by Table 19.1.6.2.

B. Corrected 01/07/15.

Based on random observation during the survey walk-through and document review, not all portions of the facility's commercial cooking equipment is installed and maintained in accordance with NFPA 96. These deficiencies could affect any patients, staff, or visitors in the building because fires could develop in the Kitchen and building occupants may not be notified of the fire condition.

Findings include:

A. Corrected 06/04/2014.

B. Corrected 06/04/2014.

C. During the document review process conducted at 9:03 AM on February 19, 2014, the report from the provider's kitchen hood suppression system testing vendor dated February 7, 2014 stated that the kitchen hood suppression system is not compliant with UL 300 as required by NFPA 96 1998 7-7.2.

D. Corrected 06/04/2014.

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 staff interview, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system as required by NFPA 99. These deficiencies could affect any patients, staff, or visitors in the building because the emergency electrical system (EES) could become compromised.

Findings include:

A. During an interview held in the Nursing Unit Clean Supply Room (which houses several electrical panels) held at 2:34 PM on February 18, 2014, the provider's Maintenance Manager stated that the building does not have a Type 1 Emergency Electrical System as required by NFPA 70 1999 Article 517 and NFPA 99 199 3-4.2.2.2.

Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any patients being treated in the cited areas because emergency power may not be available under certain conditions, or may affect any patients, staff, or visitors in the building because the fire alarm system could become compromised.

Findings include:

A. Corrected 01/07/15.

B. Patient bed locations were observed at which at least one duplex outlet served by the building's normal power system is not provided as required by NFPA 70 1999 517-19(a). locations observed include:

1. 2:29 PM February 18, 2014: 2 Stage I Recovery Bays in Surgical Department PACU.

2. 9:50 AM February 19, 2014: 2 Treatment Rooms in Emergency Department.

3. 9:52 AM February 19, 2014: 2 Treatment Bays in Emergency Department Trauma Room.