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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.

Based on random observation during the survey walk-through and staff interview, the facility's Type 1 Emergency Electrical System (EES) is not divided into the Life Safety Branch, the Critical Branch, and the Equipment Branch as required by NFPA 99. These deficiencies could affect any patients, staff, or visitors in the building because the EES could become compromised.

Findings include:

A. The facility's Type 1 EES was observed to not be divided into a Life Safety, Critical, and Equipment Branch as required by NFPA 99 1999 3-4.2.2.2. and NFPA 70 1999 517-30. All Electrical Panels listed below were observed to serve electrical loads which are required to be served by different branches of the EES. Electrical Panels at which this condition was observed include, but are not limited to:
1. 11:57 AM April 8, 2013, Panel EX1, located in the Third Floor Center Equipment Room.

2. 1:56 PM April 8, 2013, Panel LPE-20, located in the Second Floor West Corridor.
3. 2:42 PM April 8, 2013, Panel X1, located in the First Floor Electrical Room.
4. 2:43 PM April 8, 2013, Panel X, also located in the First Floor Electrical Room.
5. 2:45 PM April 8, 2013, Panel HER, located in the First Floor Emergency Department Electrical Room.

6. 2:46 PM, Panel EER, also located in the First Floor Emergency Department Electrical Room.

7. 8:19 AM April 9, 2013, Panel XP5, located in the First Floor Boiler Room.

8. 8:20 AM, April 9, 2013, Panel XP6, also located in the First Floor Boiler Room.

B. The facility's Type 1 EES was observed to lack a separate transfer switch for each branch of the system (Life Safety, Critical, and Equipment) as required by NFPA 99 1999 3-4.2.2.1. and NFPA 70 1999 517-30(b)(4). During an interview held in his Office at 8:05 AM on April 9, 2013, the provider's Maintenance Supervisor confirmed that the facility has only 2 transfer switches, and that each of these serves a combination of Life Safety, Critical, and Equipment Branch loads.

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. During an interview conducted in Second Floor Patient Sleeping Room 236 at 2:04 PM on April 8, 2013, the provider's Maintenance Supervisor confirmed that not all patient headwall locations in Patient Sleeping Rooms are provided with at least 1 circuit from the Critical Branch of the building's Type 1 Emergency Electrical System as required by NFPA 70 1999 517-18(a). Locations observed include all Second Floor Patient Sleeping Room headwall locations except the west beds in the 4-Bed Patient Sleeping Room immediately east of the Nurses' Station.

B. Corrected 8-11-14.