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A fire alarm system with approved components, devices or equipment is not installed according to NFPA 72, National Fire Alarm Code, to provide effective warning and to direct staff to the source of the fire.

Findings include:

A. On 5/17/12 during the fire alarm tests locations were observed at the 2nd floor nurse station where the flash from more than two strobes are visible and not synchronized in accordance with NFPA 72, 1999, 4-4.4.2.3.


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B. CORRECTED 01/31/13.

The fire alarm system with approved components, devices or equipment is not installed according to NFPA 72, National Fire Alarm Code, to provide effective warning and to direct staff to the source of the fire.

Findings include:

A. CORRECTED 02/01/13

B. On 5/17/12 during the fire alarm tests locations were observed where more than 2 strobes are visible and not synchronized in accordance with NFPA 72, 1999, 4-4.4.2.3. Locations include:

1. Main - 8th floor
2. Main - 7th floor


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Based on random observation during the survey walk-through on May 15, 2012, not all portions of the building fire alarm system are maintained in accordance with 19.3.4 and NFPA 72.
Findings include:

C. CORRECTED 02/01/13

D. The strobes in the Kitchen were not syncronized to comply with NFPA 72-1999, 4-4.4.2.3.


16339


E. CORRECTED 02/01/13


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F. CORRECTED 01/07/15

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 to comply with 19.2.3.3. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

A. May 15th 2:15pm 4th floor, ICU Corridors contain numerous mobile nurse computer stations - located one between every second room. Each station contained one to two chairs located in front of them. The corridor exceeded 8 feet in width, however, the depth of the station alone exceeded the 7 inch distance of intrusion allowed by the life safety code.
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A. CORRECTED 02/01/13


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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, 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.

B. CORRECTED 02/01/13
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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.
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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches. Examples include the elevator room panel EPA, (equipment branch?), serves all of the cab lighting that should be served from the life safety panel, and panel L1A a life safety panel serves the security camera and receptacles that should be fed from a critical panel. These examples and other locations throughout the building do not meet the requirements of NFPA-70, Section 517-31 thru 35.
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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches. In several locations the critical panels are serving exit signs, stairwell lighting, elevator lights, and med gas alarms that should be served from the life safety panels which does not meet the requirements of NFPA-70, Section 517-31 thru 35.
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Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches. In several locations, life safety panels are serving items such as nurse's stations that should be served by the critical panel, and the critical panels are serving fire alarm and med gas panels that should be served from the life safety panels which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

New 01/07/15: The work to complete the Emergency power system throughout the Medical Center Complex to separate the life safety circuits, critical and equipment branch circuits did not meet the completion date of 11/30/14 noted on the PoC.




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B. CORRECTED 01/07/15

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.

Findings include:

A. The emergency power panels are not properly separated into the life safety, the critical and the equipment branches. In several locations, life safety panels are serving items such as nurse's stations that should be served by the critical panel, and the critical panels are serving fire alarm and med gas panels that should be served from the life safety panels which does not meet the requirements of NFPA-70, Section 517-31 thru 35.
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