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A) The A Building is identified as Type II (222) Construction (as defined by NFPA 220). The floor/ceiling assembly above the 3rd Floor and 2nd floor is comprised of:

Concrete over metal deck with open web steel joists (bar joists). In some areas there is a monolithic ceiling with a lay-in ceiling below. The lay-in ceiling has mineral wool blankets around recessed 2 x 4 fluorescent light fixtures and mineral wool blankets over HVAC diffusers in ceilings.

Based on observation and docuemnat review and/or the lack of documentation, the surveyor finds that the provider is not able to demonstrate that the facility complies with the minium construction type requipments in accordance with 19.1.6.2.

1) The provider lacks documentation that shows how the above complies as a two hour fire rated floor/ceiling assembly.

2) The mineral blanket is partially missing at recessed light fixtures. Examples include:

a) 3rd Floor, above the ceiling west of the
fire doors between the A and B Building

b) 2nd Floor, above the ceiling west of the
fire doors between the A and B Building

3) The Rehab Waiting Room (Room 152) is located in Building A. However, the structure directly above is precast concrete supported by unprotected steel angles that are bolted to the two hour wall between building A and B. These steel support angles are not fire proofed to comply with the requirements for Type II (222) construction.

Failure to maintain fire rated structural assemblies could cause structural failure during a fire.

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A. Based upon observation the surveyor finds that corridor doors lack positive latching hardware in accordance with 19.3.6.3. Failure to install and maintain hardware on corridor doors would allow fire or smoke to spread into rooms or from rooms to corridors.

Findings include:

1) The 3rd Floor East Building Staff Lounge has a corridor door that does not latch (the strike receiver in the door frame is missing and the latch does not engage).

2) The 1st Floor Rehab space has an auto-open corridor door that does not latch at any time (does not latch when fire alarm is activated).



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B. Based on observation it was determined that the facility failed to maintain closure for corridor doors in accordance with UL tested design assemblies and NFPA 101, 19.3.6.3.2. Findings include:

1) Building "D" - The Life Safety Plans identify cross corridor double doors at a designated 1 hour fire rated wall which leads to the NW exit stair doors / elevator foyer. The doors are not equipped with positive latching hardware. This condition occurs on floors on 6th, 5th, 4th, 3rd, Basement and Sub-Basement in Building "D".

A) Based upon observation, the surveyors find that the HVAC system have vertical openings that are not enclosed and/or that lack fire dampers installed at duct penetrations in accordance with NFPA 90A -1999. The provider is not able to demostrate through docuemantion or visual observation how they comply with NFPA 90A. Findings include:

1) The surveyors find that the provider lacks accurate and detailed information that incudes: the location of every duct riser or vertical duct shaft, the fire ratings for such shafts and the locations of fire dampers at fire rated floor assemlbies or at the floors and walls of fire rated shaft penetrations (see also K067). The surveyors also find that most of the locations that need to be observed are occupied by patients and access above the ceiling is not feasible. (The provider is not able to provide access for visual confirmation of compliance with NFPA 90A.)

a) The supply distribution and window
induction units on multiple floors do not
comply with NFPA 90A -1999 and/or
Section 903 of NFPA 90A - 1974. The
induction units on all floors of the A
Building including some of the
Basement areas are supplied by vertical
supply risers between each of two side
by side rooms (at the outside walls).
The induction units are fed via a 2" or 3"
round supply pipe that runs from the
vertical riser into the side of each
induction unit.

i) The vertical supply risers are fed
from a 4th Floor air handling units.
Duct penetrations for the risers fed
directly from the mechanical room
have fire dampers at the floor
penetration. The Conference Room
and the Pharmacy both have a fire
damper at the 4th Floor, floor
penetrations. Fire dampers and/or
access to fire dampers was not found
at the other supply risers at the 4th
Floor.

ii) From observation on
multiple floors the surveyor finds
that the horizontal round duct feed
into each induction unit on the 3rd,
2nd, 1st Floor and Basement Levels
are not sealed where the round duct
penetrates the vertical shaft
enclosure. Inspection for this
condition is nearly impossible to
observe without special equipment.

b) The facility also has bathroom exhaust
ducts on multiple floors that are directed
to fans on the roof above the 4th Floor.
The provider was not able to provide
information as to how the exhaust ducts
reach the roof with fire rated shaft
enclosures and fire dampers at all shaft
penetrations.

Failure to maintain accurate information will prevent adequate maintenance of fire dampers and rated shaft enclosures. Failure to install and maintain shaft enclosures and fire dampers will allow fire and smoke to spread from floor to floor and impact significantly on patient safety.

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B) Based on random observation during the survey walk-through, not alll shaft are constructed or maintained as fire resistive assemblies in accordance with NFPA 101, 19.3.1.1. Finding includes:

1) 1997 B Building - First Floor, The ventilation system from the Penthouse serving 4th Floor through the First Floor level was installed without or lacking fire rated shaft enclosures to comply with 8.2.3.1.1. This was observed above the ceiling of the Receiving Area near the pipe chase and the double door by the Elevator.

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Based on random observation during the survey walk-through, not all portions of the facility's floor slabs are maintained and fire rated in accordance with NFPA 101 2000. Findings include:

A. During the survey of the second floor storage room on the afternoon of March 12, 2012 the room had 1" plastic PVC pipe connected to 1" copper line penetrating the 2 hour floor slab without proper protection to maintain the slab penetration fire rating in accordance with 8.2.3.2.3.1 (1).

These deficiencies could cause patients and staff injury by allowing products of combustion to travel from floor to floor.
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A. From observation the surveyors find that fire rated doors and/or smoke doors do not comply with 19.2.2.2.6 and 7.2.1.8.2. Failure of complete door closure compromises the ability of the barrier to restrict the movement of fire and smoke from one side of the barrier to the other. Findings include:

1) From observation during fire alarm testing on the morning of 3/14/12, the surveyors find that the pair of smoke doors located at the east end of the west smoke compartment (of the East Building)(near the convenience stair) do not close completely when the fire alarm activates - i.e. the doors do not close to a smoke tight condition and do not comply with 7.2.1.8 of NFPA 101.

2) On 3/14/12, the surveyor observed that the corridor door to the 1st Floor Pharmacy has a magnetic hold open device that did not release from the activation of a local smoke detector in accordance with 7.2.1.8.2.

A) From review of the provider's Life Safety Plan that surveyor finds that smoke barriers are identified on plans. However, from observation, the surveyor finds that designated smoke barriers are not constructed and maintained to comply with 19.3.7.3 and 8.3. Failure to maintain smoke barriers could result in smoke migration during a fire to multiple smoke compartments. Findings include:

1) The 3rd Floor East Building smoke barrier near Room 206 has one sleeve above the ceiling with yellow cables running through the sleeve. The sleeve interior is not sealed for fire rated construction.


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2) Building "D" - 2nd Floor, the designated 1 hour fire wall by the Anesthesiologist Room has conduit and sprinkler pipe penetrations that are not smoke sealed to comply with 8.3.6.1.

A) Based upon observation the surveyor finds that hazardous areas are not enclosed in accordance with 19.3.2.1: Findings include:

1) Patient Room 209 is being temporarily used as a storage room. The corridor door lacks self closing hardware in accordance with 19.3.2.1. The corridor door lacks interim measures that include a sign on the door to keep the door closed.

Failure to maintain this temporary room as a hazardous area could result in a fire that is not contained within the room and thus jeopardize patient safety.

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B) Based on random observation during the survey walk-through, not all hazardous area are separated from the remainder of the building in accordance with 19.3.2.1. and 8.4.1. These deficiencies could affect any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors in the event of a fire condition.

1) 1997 B Building - 2nd Floor OR Unit, the door to the Soiled Utility Room was observed to not be labeled or to carry a minimum 3/4 hour fire resistance rating required by NFPA 101-2000, 19.3.2.1.

2) 1997 B Building - First Floor: The door to the designated 1 hour fire rated separation wall for the Receiving Room was not labeled and does not positively latched to comply with 8.2.3.2.1.
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A) Based upon observation the surveyors find that exit enclosures do not comply with Chapter 7 of NFPA 101. Findings include:

1) The West Stair (stair to the roof) has a black antenna cable inside the stair enclosure at the roof level that does not comply with 7.1.3.2.1 e).

Unapproved materials in exit enclosures could create smoke or fire and could interfere with use of the stair as an exit.

2) Multiple stairs serve five floor levels and do not have stair identification signage inside the stair in accordance with 7.2.2.5.4. The only identification inside the stair is the floor level. (examples include the West Stair which serves the 1st Floor to the roof level and the Stair next to the Cafeteria which serves the Basement Level to the 4th Floor -both are five story stairs.)

Lack of stair identification could lead to confusion during exiting and confusion by personnel that must use the stair in an emergency.

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B) Based on observation during the survey walk-through, not all exit enclosures are maintained as fire resistive assemblies in accordance with 19.3.1.1, 7.1.3.2. and 8.2.3. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building. Findings include:

1) 1997 B Building - First Floor, East Stair exit discharge was observed with a ventilation air supply penetration through the two hour fire rated wall near the Administration Office Room. The duct opening does not independently and solely serve this stair and is therefore not in compliance with 7.1.3.2.1(e).
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A) Based on direct 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 an exit from the building. Findings include:

1) Building "D" - 6th Floor: A T.V. and a T.V. cart are being stored under the landing of the Penthouse exit stair and do not comply with 7.1.3.2.3.

A) Based upon observations that surveyors find that exit area not readily available at all times. Findings include:

1) West Exit Stair (stair to the roof) The stair door to the roof has a latching device that does not work. Instead a slide bolt is used on the door. The slide bolt is not operable from the roof side of this door.

2) The former main entrance lobby at the 1st Floor Northwest portion of the "A" Building has been converted into a patient treatment area (Rehab). The plans provide for this survey are not accurate for this part of the building. The elevator lobby for the pair of elevators is part of the means of egress from the 1st Floor patient wing. This elevator foyer has an exit sign (at the cafeteria stair) and an exit sign above the pair of doors to the Rehab Unit (exit access corridor is directed into a patient treatment area). This pair of doors also has multiple signs that indicate "do not enter".

i) The exit path can not be directed from a
corridor into patient treatment rooms
(19.2.5.9, 19.3.6.1).

ii) The exit sign conflicts with the do not
enter signs on the doors.

3) The 1st Floor office and storage functions in the area north and east of the Rehab space lack a 2nd means of egress that does not require travel through the Rehab space. The exit sign on the door from this area into the Rehab space has signage on the door that indicates "do not enter."

These deficiencies compromise the proper exiting of all occupants required to utilize the exit paths.
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A) The survyeor finds that designated fire barriers are not maintained in accordance with 8.2.3.2.4.2 of NFPA 101.

1) Based on observation, the surveyor finds that one penetration through a designated two hour fire barrier (in Room 152) above the ceiling is not sealed for two hour construction.

Failure to maintain fire barriers could result in spread of fire and smoke past fire and smoke barriers.
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A) Based on observation during the survey walk-through, not all portions of the facility's exit egress lighting are in accordance with NFPA 101 2000.

Findings include:

1) During the survey on the morning of March 12, 2012, the south exit ramp was observed to have four lighting fixtures that are not of the type of fixture (not manufactured) that would light the exit discharge path within 10 seconds of normal power failure in accordance with 7.9.1.2.

This deficiency could cause injury to patients and staff due to improper illumination.
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A) Based on observation during the survey walk-through, exit signs were not provided or were not fully visible to designate the path of egress in all cases 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:

1) Building "D" - 6th Floor the south end corridor serving the Meeting Room and the Elevator Lobby lack illuminated exit signage to direct occupants to the building exit.

2) Building "D" - 5th Floor, Business Office the exit corridor near the Women's and Men's Toilet Rooms lack an exit sign to direct occupants to all available exit.

3) A Basement Level exit access corridor in north side of the East Building (corridor with Telephone Rooms) is directed into the West Building through a four hour vestibule. The exit path in the East Building lacks an exit sign above the fire doors to the west.

A) Based on document review and staff interview, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. This deficiency could affect all patients as well as any staff and visitors present, because the failure to maintain any of those components could result in smoke or fire passing from one part of the building to another. Findings include:

1) It was determined through random comparison of observed condition for specfic life safety items in the field to those identified on plans and confirmed via staff interviews that the facility's fire protection plan (Life Safety Plans) required by 19.7.1.1 are not accurately drawn and updated. Critical building components, key building data, or elements of building fire protection systems which could not be properly identified include (but not necessarily limited to):

a. Fire barriers and their fire resistance
ratings, horizontal exits, building
separations between disparate
construction types. Example: 4 - hour
rated "Chicago vestibule" are not
consistently and clearly identified on
every floor of the Life Safety Plan.
Locations observed on Second Floor
Plan, and Basement Plan of Building
"D".

b. Shaft enclosures and their fire resistance
ratings, including exit stair enclosures,
elevator or ventilation shafts. Example:
Sub Basement Life Safety Plan for
Building "B", "C" and "D".

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A) Based upon observations, review of fire alarm testing doucmeantion and based on interiview of personnel, the surveyors find that the fire alarm system is not installed and maintained in accordance with 19.3.4 and NFPA 72-1999. These deficiencies can effect the proper notification and response of occupants to a fire/smoke condition. Finding include:

1) Supervisory signals (from electronic supervision of tamper switches and other supervisor alarms) and fire alarm trouble conditions are not transmitted automatically to a constantly attended location. The only location that constantly monitors the fire alarm system is the 1st Floor Entrance Reception Desk. This location does not receive any additional supervisory or trouble signals from the fire alarm system after the fire alarm city tie in is turned off and the audible trouble bell for this is silenced.

a) The main fire alarm panel receives
additional signals but is not constantly
attended.

b) Based upon document review, the
surveyor finds that the provider routinely
disables the city tie in for projects. The
provider lack adequate interim life safety
measures for the lack of supervisory and
trouble monitoring of the fire alarm
system.

2) Based upon random testing on 3/14/12, the surveyors find that the staff notification portion of the fire alarm system (chime code) does not comply with audibility requirements of NFPA 72 and that the chime code is not distinctive enough to be identified.

a) The annunciation device on the 3rd
Floor next to the Montrose Stair failed to
activate. This was the only annunciation
device in this smoke compartment.

b) The surveyors observed that all smoke
compartments of the East Building on
the 3rd Floor have corridors where nurse
call signals and/or ventilator alarm
signals are activated continuously and for
extended periods of time. These signals
are louder than the fire alarm system.



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A) Based on observation, the surveyors find from observation that fire alarm devices are not installed in accordance with NFPA 72

1) Building "D" - 3rd Floor Psych Unit-Laundry Room contained a smoke detector located within 3' of the air supply diffuser and not in accordance with NFPA 72-1999, 2-3.5.1.


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C) During the survey of the four elevator penthouses heat detectors were observed to be more than 2' from the sprinkler heads and not in accordance with NFPA 72 3-9.4.2. These deficiencies could cause injury to patients and staff by subjecting them to electrical current, due to sprinkler discharge. Locations include:

1. The North East penthouse.

2. The South East penthouse.

3. The South West penthouse.

4. The North West penthouse.

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A) Based on observation and document review on the morning of March 14, 2012, the surveyor finds that not all portions of the facility's fire alarm are tested and maintained in accordance with NFPA 72 1999. Failure to properly test fire alarm system components could cause patient and staff injury. Findings include:

1) During the review of records, the document for smoke detector testing dated August 1, 2011 indicated 11 smoke detectors failed testing and no corrective action was documented in accordance with 7-5.2.2.

2) The fire alarm testing report dated December 12, 2011 indicated two tamper switches inspected and not tested in accordance with table 7-3.2.

3) During the document review it was discovered a contractor service tested tamper switches annually and not semi-annual in accordance with table 7-3.2.

A) Based on random observation during the survey walk through, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). Failure to properly install a complete fire protective feature of the building compromises the complete coverage intended for occupant safety.

1) Based upon random observation the surveyor finds that the air handling room in the Basement Level, East Building Dry Stores Room is not sprinklered or the sprinkler head is obstructed and not visible.


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2) Building "D" - Fifth Floor, the provider was not able to demonstrate where and how the sprinkler coverage is provided for the Linen Chute in accordance with NFPA 13.

A) Based upon document review for the past 12 months, the surveyors find that the electric fire pump is not tested annually on emergency power, in accordance with the sequence and requirements of NFPA 20 and NFPA 25.

Failure to test the fire pump on emergency power could cause failure of the fire pump during the loss of normal power.

B) Based upon document review for the past 12 months the surveyor finds that the sprinkler systems are not inspected, tested, serviced and maintained in accordance with NFPA 25. Findings include:

1) Quarterly flow testing of every flow switch using the inspector's test valve for each zone is not tested and documented quarterly.

a) Of the four quarters for 2011, the
provider indicates that no testing was
conducted for the 2nd quarter of 2011.

b) The quarterly flow testing that is
documented for December of 2011
includes the location of each inspector's
test valve but does not identify the time
from water flow to fire alarm activation
for each device.

2) Annual documentation of one anti-freeze loop system is not available with: the chemicals used, specific gravity and low point temperature recorded.

3) The annual documentation for the "wet" sprinkler system is incomplete and not in accordance with NFPA 25 - 1999.

a) The testing/inspection documentation for
June, September and December of 2011
identify the same sprinkler deficiencies.
The provider lacks documentation that
demonstrates when and how each
deficiency was corrected.

b) The sprinkler report dated 9/27/11 is
marked as a quarterly and annual
inspection. However, portions of the
form were left blank and most of the
annual inspection requirements are
marked "NA" (not applicable).

4) The sprinkler report dated 6/23/11 is identified as an annual inspection report. The five year inspection of sprinkler gauges is marked "not applicable". The provider lacks documentation that shows when sprinkler gauges were last tested or replaced.

Failure to test and maintain the sprinkler system could cause failure of this system during a fire. Failure to correct sprinkler deficiencies in a timely manner could cause a failure during a fire.

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A) Based on observation the surveyors find that HVAC systems do not comply with NFPA 90A and/or ASHREA requirements. Examples include:

1) MUA -E1 is a rooftop HVAC Package air handler with an air intake located four feet from a plumbing vent through the roof.

2) The negative air isolation room on each floor has an ante-room with a pressure monitoring device. This device measures air pressure between the patient room and the ante room. The monitor does not send an alarm outside of the ante room and the air pressure between the isolation room and the corridor is not monitored electronically and/or physically using smoke (smoke test under door per CDC guidelines).

B) From observation and personnel interview, the surveyor finds that the West Wing had no functioning chiller system at the time of this survey. The provider has taken the chiller off line and initiated a construction project that will take five to six weeks to complete.

1) The surveyor notes that this project was not submitted and approval was not received from the Department in accordance with Hospital Licensing Requirements. The surveyor observed that the project lacked interim life safety measures.

a) The West Building has two 2nd Floor
High Acuity patient units. At 1:30PM
on March 13th the outside air
temperature reached 80 degrees. The
two High Acuity Units were observed
with portable air cooling units. The
temperature was 78 degrees in the older
High Acuity Unit. The provider did not
know what the humidity was in this unit
and was unable to indicate what
temperature or humidity levels were
acceptable to the patients within the unit.

b) The exhaust air from the portable
cooling units was directed into the
ceiling cavity of the High Acuity Unit
(the provider indicated that they were
supposed to be ducted into exhaust
ducts).

c) Power to these portable cooling units
was provide via extension cords that
were fed up into the ceiling cavity and
across the ceiling to remote outlets in an
office.

d) Immeidate interim life safety measures
were required by the surveyor.

e) 2nd Floor Clean Utility Room (no room
number) with Steris Scope cleaning
equipment. The room has a portable
cooling unit that is exhuasted in the
ceiling cavity of an otherwise clean
room.

C) Based on observation the surveyors find that HVAC distribution systems are not installed and maintained in accordance with NFPA 90A, NFPA 101 Section 8.5 and 19.3.6.1. Findings include but are not limited to:

1) There is a four hour fire rated vestibule between the East and West Buildings on each floor. A duct shaft was observed directly south of this vestibule.

a) The duct shaft is not identified on plans
as a fire rated shaft enclosure.

b) There is a plenum air opening or relief
opening from the duct shaft into the
ceiling cavity of the vestibule. This
opening is not connected to any
ductwork. A fire damper is installed at
the opening but a smoke damper and a
smoke detector is not installed. The
opening is not protected to maintain the
vestibule wall as a smoke resistant wall
above the ceiling in accordance with
19.3. The unducted opening also does
not comply with 19.3.6.4 and 19.3.7.3.

Locations include:

i) 4th Floor four hour vestibule -
opening in south wall above ceiling

ii) 3rd Floor four hour vestibule-
opening in south wall above ceiling.

iii) Basement Level four hour vestibule
with opening in south wall and west
wall.

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Based on random observation and document review during the survey walk-through on the morning of March 14, 2012, not all portions of the facility's heating, air conditioning and ventilating system are installed in accordance with NFPA 90A 1999.

Findings include:

D. The northeast penthouse was observed to have ducts penetrating the penthouse floor without a fire damper installed in accordance with 3-3.2. Items observed were;

1. Large supply duct from the ceiling
mounted AHU.

2. Smaller exhaust duct in the same shaft.

E. The northwest mechanical room 8214 on the sixth floor was observed to have no access panels installed to verify if dampers exist and not in accordance with 2-3.4.1. Ducts observed were;

1. The large rectangular duct.

2. 3 round ducts at the same location.

F. During the document review process records indicated dampers were inspected and no records of testing full closure with the fusible link removed in accordance with 3-4.7.

G. During the survey process building ventilation prints were not available to show the location of fire, smoke and combination dampers throughout the facility in accordance with 3-4.6.1.

These deficiencies could cause injury to all patients and staff during a fire.
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A) Based on observation the surveyors find the Kitchen Exhaust Duct (cooking system grease duct) is not installed and maintained in accordance with NFPA 90A-1999 and NFPA 96-1998 or in accordance to the equivalent NFPA Standards at the time of original construction. Findings include but are not limited to:

1) The kitchen exhaust duct fan is located within a space above a 5th Floor North Mechanical Penthouse. The Kitchen Fan shares the same space with a supply air handler (MUA-N1 - which supplies environmental air to the 4th Floor corridors). The Kitchen Fan is not installed in a space that is separated from the air handling equipment in accordance with NFPA 90A. The Kitchen fan is also shares the same space with a traction elevator machine room and elevator shaft.

2) The kitchen exhaust duct shaft extends from inside a 5th Floor penthouse to the Basement Level.; it is not clear how this portion of the shaft is vented to the exterior. (NFPA 96, 4-7.1).

3) The kitchen exhaust duct shaft is open to the ceiling cavity of the Basement Level next to the Northeast (B) Elevator.

4) The Kitchen exhaust duct is not continuously enclosed in a separate two hour fire rated shaft enclosure from the Kitchen at the Ground Floor to the roof of the upper penthouse. From observation, the surveyor finds that the Kitchen exhaust duct shares the same "shaft" with other ducted systems and that this shaft is open to the ceiling cavities of multiple floors.

5) The Kitchen exhaust duct from the Basement Level East Building Kitchen hoods extends north and west above the ceiling. There is a branch duct that extends north off of this kitchen duct above the ceiling. This branch duct is capped off and is not constructed of black iron or seamless stainless steel in accordance with NFPA 96.

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B) Based on observation and document review during the survey walk-through on the morning of March 14, 2012, not all portions of the facility's commercial cooking equipment are installed and maintained in accordance with NFPA 96 1998.

Findings include:

1) During the document review process records dated March 11, 2011 was the last time a contracted service cleaned the hood and not in accordance with 8-3.1 for every 6 months for a moderate cooking facility.

2) During the survey of the penthouse location, the hood exhaust fan housing was observed without a drain connection to a sealed container with less than one gallon capacity in accordance with 5-1.2.2.

3) During the survey of the penthouse location, the hood exhaust fan housing was observed with a flexible connection to the ductwork and not in accordance with 5-1.2.1.

4) During the survey of the penthouse location, the hood exhaust fan housing was observed without proper clearances for servicing the unit in accordance with 5.1.3.

5) Ductwork from the hood location to the fan location was observed without an access panel located horizontally and vertically at each floor level for cleaning purposes in accordance with 4-3.4.3.

These deficiencies could cause injury to patients and staff due to a fire in the ductwork.
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Medical gas storage is not in compliance with NFPA 99-1999. Failure to properly secure tanks and systems could cause injury to occupants. Conditions observed include:

A) The surveyor observed an unsecured oxygen tank in a niche in the 2nd Floor Corridor, opposite the Nurses Lounge. The tank was not secured in accordance with NFPA 99.
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A) Based on observation during the survey walk-through, not all piped-in medical gas systems are installed and maintained in accordance with NFPA 99, 1999, 4-3.1.2.3(d).
Findings include:

1) (Added 03/29/12): Manual medical gas shutoff (zone) valves were observed that are located in the same room as the station outlets they serve, to comply with NFPA 99 1999 4.3.1.2.3.d.

Locations observed include: Building 1997 Second Floor ICU Suite known as HAU.

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B) Based on observation during the survey walk-through on the morning of March 13, 2012, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999 Chapter 4. Findings include:

1) During the survey of the basement east mechanical room, the medical vacuum system was observed to be suppling a manifold distrubution header with 4 valves to shut off valves for certain areas of the system without identification attached to the valves in accordance with 4-3.1.2.14 (b).

2) During the facility survey three medical vacuum systems were observed with common manifold exhaust piping without a check, manual valve or other means for isolating one pump so the other could supply the needed vacuum in accordance with 4-3.2.1.9. Locations include;

1. "A" building fourth floor boiler room.

2. Basement east mechanical room.

3. The new medical vacuum in the penthouse.

3) During the facility survey, two medical vacuum systems were observed without a shut off valve at or near the receiver in accordance with 4-3.2.2.6 (c). Locations include;

1. The new system in the penthouse.

2. The fourth floor boiler room.

These deficiencies could cause injury to patients by system malfunction or staff closing the wrong valves.
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A) K130 Interim Life Safety Measures: 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.

1) The facility does not comply with NFPA 101 and lacks adequate interim measures for all cited deficiencies.

B) Based on observation the surveyors find that plumbing installations do not comply with the plumbing code. Findings include:

1) 4th Floor Pharmacy: Plumbing wall penetrations under sinks are not sealed against pest infestation in accordance with the plumbing code.

2) Electrical closet 216: There are two sinks in this room with no trap seal (the trap seal has evaporated exposing the room to sewer gasses). The sinks were also filthy.

3) Electrical Closet 120: a sink has been removed; however the faucet and water supply was not terminated in accordance with the plumbing code.
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A) Based on observation during the survey walk-through on the afternoon of March 13, 2012, not all portions of the facility's safety eye wash stations are installed and maintained in accordance with NFPA 99 1999. Findings include:

1) During the survey of the facility, eye wash stations were observed to be installed without pressure and temperature regulating valves to prevent injury to staff in accordance with 10-6.

Locations include but may not be limited to; The Laboratory eye wash was without dust covers to prevent contamination.

The deficiencies could cause staff injury.
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A) Based upon document review, the surveyors find that two of two emergency generators are not exercised monthly under load in accordance with NFPA 99.

1) The documentation for monthly load testing does not include the amperage load for three of three phases for each generator.

B) Based upon document review, the surveyor finds that battery operated emergency lighting is not tested monthly and annually in accordance with 7.9.3 of NFPA 101. The provider has periodic maintenance documentation that indicates that all battery operated lights are tested monthly and annually; however the documentation does not identify the location of each device tested and/or does not indicate the total quantity of devices tested (example: 12 of 12 devices were tested on February 30, 2012).

Failure to test in accordance with the referenced standard could cause failure in an emergency.
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Based on random observation during the survey walk-through on the afternoon of March 12, 2012, not all portions of the facility's emergency electrical system are in accordance with NFPA 99 1999. Findings include:

A. During the survey of the "B" building, emergency electrical panels were observed to be identified as "EM" and not as life safety, critical or equipment branch in accordance with 3-4.2.2.2. An example is, but may not be limited to:

1. The third floor electric room contained panel EM #5 with breaker 38 serving the oxygen alarm instead of it being supplied by the life safety branch in accordance with 3-4.2.2.2. (b).

Failure to provide proper distribution and labeling of emergency power could jeopardize the use of emergency power for patients when the system is relied upon for patient safety.
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A) Based upon random observation the surveyor finds that electrical installations are not installed and maintained in accordance with NFPA 70: Findings include:

1) Electrical extension cords are used where electrical outlets would be required for permanent use. Locations include:

a) 4th Floor Plant Operations Office

b) 4th Floor I V Room near window
induction unit

c) Office 238

d) Basement Radiology Office

The use of extension cord for other than limited temporary use could result in a fire or electrical short.

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B) Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999). Findings include:

1) 1997 B Building - 3rd Floor, Electrical Room 364: The Electrical Panel - CR3B directory is not accurately labeled to comply with NFPA 70 1999 384-13.

Failure to properly and accurately label the use of circuits could effect all occupants' safety when selected services must be temporarily disconnected for repair or maintenance.
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