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Based on observation during the survey walk-through, not all interior finishes of rooms comply with applicable requirements of the Life Safety Code. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, because the lack of compliance can expose occupants to harmful fire and smoke conditions.

Findings include:

A. At 10:35am on 7/22/14 the Radiology #1 room and portions of the adjacent dressing room on the 1st floor were observed to have painted wood paneling wall finish to a height of 8' which could not be documented by staff at the time of the survey to meet the minimum finish rating requirements of Class A or Class B to comply with NFPA 101-2000, 19.3.3.2 (1) as an existing finish.

Based on observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 18.3.6.1. These deficiencies could affect all patients in the locations, as well as any staff and visitors present, because the lack of smoke detectors leaves the exit access corridors unprotected against early and prompt notification of a fire event that could render the exit access corridors unusable.

Findings include:

A. At 10:45am on 7/22/14 it was observed that the 1st floor Radiology reception office was considered to be located in the Emergency Department Addition sprinklered smoke compartment and was open to the corridor and indicated not to be staffed or observed on a 24/7 basis. The reception office area is not provided with smoke detection to comply with 18.3.6.1, Exception No. 1, (c).

B. At 10:46am on 7/22/14 it was observed that the 1st floor Radiology Waiting area adjacent the main lobby information/reception desk considered to be located in the Emergency Department Addition sprinklered smoke compartment was open to the corridor and was indicated not to be staffed or observed on a 24/7 basis. The waiting area ceiling cavity is not provided with smoke detection to comply with 18.3.6.1, Exception No. 2, (b).

Based on observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. At 2:00pm on 7/21/14 it was observed that the double egress doors at the entrance to the west wing Surgery Clinic suite has the south door equipped with manual flush bolts to permit securing of the suite doors after hours. The top flush bolt lever was damaged to prevent the full closure of the north door. Confirm that the south door is not also equipped with panic device hardware which would be inoperable when the manual flush bolts are engaged. The doors are not considered resistant to the passage of smoke to comply with 19.3.6.3.1 when not able to fully close. The flush bolt latching of the door prevents the intended operation of the panic device hardware on the door in noncompliance with 7.2.1.5.6.

B. At 2:15pm on 7/21/14 it was observed that the west wing former patient shower room was being used for storage of pharmacy supplies of combustible material/cardboard packaging. The room is less than 50 sf but constitutes a degree of hazard greater than that normal to the general occupancy due to the type and density of combustible materials. The room is not sprinklered or 1-hour enclosed to comply with 8.4.1.1. The room door contains a louver in non-compliance with 19.3.6.4 when the room is utilized for other than the shower function.

C. At 2:30pm on 7/21/14 it was observed that the corridor doors to the former OR suite area were equipped with manual flush bolts and panic hardware on the south door of the pair in noncompliance with 7.2.1.5.6. The panic device provides vertical rod latching of the door but is not required or permitted when used in combination with the manual flush bolts. The currently unoccupied area does not require both doors to be operational. The north door with the keyed latchset provides required ingress and egress from the space when the south door is secured with the flush bolts.

Based on observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.2.3. These deficiencies could affect all patients in the locations, as well as any staff and visitors present, because the lack of required protection can permit fire and smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. At 1:45pm on 7/21/14 it was observed that the 2nd floor former nurse station now used as a medication room contained a sliding pass-thru window. The smoke compartment is not sprinkler protected and the window system is not minimum 1/2-hour fire rated or resistant to the passage of smoke to comply with 19.3.6.2.1, 19.3.6.2.2 & 19.3.6.2.3.

B. At 2:15pm on 7/21/14 it was observed that the 2nd floor former nurse station along the corridor leading to the former surgery/delivery area contained a sliding pass-thru window constructed of wire glass in aluminum framing. The smoke compartment is not sprinkler protected and the window system is not minimum 1/2-hour fire rated or resistant to the passage of smoke to comply with 19.3.6.2.1, 19.3.6.2.2 & 19.3.6.2.3.

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies that restrict the movement of smoke in accordance with 19.3.7.3 and 8.3.4.1. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

The finding is:

A. At 10:00am on 7/22/14 it was observed that the designated 1st floor smoke barrier wall indicated on the available Life Safety Plan passed through the rear door of the elevator near the center stair. The elevator doors do not comply with 8.3.4.1 relative to being resistant to the passage of smoke and do not remain closed upon activation of the elevator recall system.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with NFPA 101-2000, 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. At 1:15pm on 7/21/14 it was observed that the 2nd floor Soiled Utility room door (near room 209) was not self-closing to a latched condition to comply with NFPA 101-2000, 19.3.2.1 and 8.2.3.2.1.

B. At 1:20pm on 7/21/14 it was observed that the 2nd floor Pharmacy rooms containing storage of materials and supplies constituted a degree of hazard greater than that normal to the general occupancy. The room is not sprinklered or 1-hour enclosed to comply with 8.4.1.1. The corridor doors are not minimum 3/4-hour rated assemblies to comply with 19.3.2.1 and 8.2.3.2.3.1.

C. At 1:25pm on 7/21/14 it was observed that the 2nd floor Nurses' Storage room (across from the former Nurse Station now used as a Medication room) was not sprinklered or 1-hour enclosed to comply with 8.4.1.1. The corridor door was not a minimum 3/4-hour rated assembly to comply with 19.3.2.1 and 8.2.3.2.3.1.

D. At 1:30pm on 7/21/14 it was observed that the 2nd floor Cardio Storage room corridor door was not self-closing to a latched condition to comply with 19.3.2.1.

E. At 1:40pm on 7/21/14 it was observed that the 2nd floor "Chart room" record storage room was not sprinklered or 1-hour enclosed to comply with 8.4.1.1. The corridor door was not a minimum 3/4-hour rated self-closing assembly to comply with 19.3.2.1 and 8.2.3.2.3.1.

F. At 2:25pm on 7/21/14 it was observed that the 2nd floor Storage room near the former delivery room was not sprinklered or 1-hour enclosed to comply with 8.4.1.1. The corridor door was not a minimum 3/4-hour rated assembly to comply with 19.3.2.1 and 8.2.3.2.3.1.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with NFPA 101-2000, 18.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. At 11:00am on 7/22/14 it was observed that the 1st floor Soiled Utility room door in the Emergency Department Addition was not labeled as minimum 3/4-hour fire rated to comply with NFPA 101-2000, 18.3.2.1 and 8.2.3.2.1.

Based on observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2.1.(a) These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by compromising the required protection of the exit stair enclosure and preventing those occupants from reaching an exit from the building.

Findings include:

A. At 2:30pm on 7/21/14 it was observed that the fire rating label on the south exit stair enclosure (from the former surgery area) was 3/4-hour and not 1-hour rated to comply with 8.2.3.2.3.1.(b).

Based on 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:

A. At 9:00am on 7/22/14 it was observed that the exterior stair from the west wing exit discharge landing had a bottom riser greater than 3/16" difference from the remaining risers of the stair in non-compliance with 7.2.2.3.6.

B. At 9:05am on 7/22/14 it was observed that the exterior door from the west exit stair had an aluminum framing member below the threshold assembly. The height of the threshold was 1.5" above the stair landing surface in non-compliance with 7.2.1.3.

C. At 9:10am on 7/22/14 it was observed that the door at the basement level of the west exit stair had a direction of swing opposite to the direction of exit travel in non-compliance with 7.2.1.4.3.

D. At 9:45am on 7/22/14 it was observed that the 1st floor Maintenance Shop door from the designated exit passageway was not self-closing to a latched condition to comply with 7.1.3.2.1(c).

E. At 10:00am on 7/22/14 it was observed that the exterior stair from the east wing exit stair discharge lacked hand railings extending the full length of the stair treads and risers to comply with 7.2.2.4.3. The bottom tread was elevated above ground surface and was greater than 3/16" difference from remaining tread depths in non-compliance with 7.2.2.3.6.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress 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:

A. At 2:20pm on 7/21/14 it was observed that exit signs were not provided to identify the 2nd means of egress from the east-west corridor in the former surgery area on the 2nd floor to comply with 19.2.5.9.

Based on random observation during the survey walk through while accompanied by the Plant Operations Director, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA-72. This could affect all occupants of the building if the fire alarm system did not operate properly during a fire emergency.

Findings include:

1. The surveyor observed that the unoccupied mechanical room near the ER housed a fire alarm NAC panel and was not equipped with a smoke detector to meet the requirements of NFPA-72, Section 1-5.6.

Based on observation during the survey walk-through, not all Medical Gas storage locations comply with NFPA 99-1999, and NFPA 101-2000. This deficiency could affect all persons required to utilize the exit by preventing those occupants from safely reaching an area away from the building.


Findings include:

A. At 10:05am on 7/22/14 it was observed that oxygen tank storage location on the loading dock containing greater than 3000 cu. ft. of medical gas was not fully enclosed with 1-hour rated construction to separate the medical gas storage from the building exit discharge to comply with NFPA 99-1999, 4-3.1.1.2(2). The labeled fire door to the enclosure was not self-closing to comply with NFPA 101-2000, 8.2.3.2.1.

Based on random observation during the survey walk through while accompanied by the Plant Operations Director, the surveyor found that not all testing requirements of NFPA-110 were met. This could effect all occupants of the building if the generator did not operate during a power outage.

Findings include:

1. The surveyor observed that the load on the generator during the monthly test did not meet the 30% requirement of NFPA-110, Section 6-4.2, and an annual load bank test was not conducted to meet the requirements of NFPA-110, Section 6-4.2.2.

Based on random observation during the survey walk through while accompanied by the Plant Operations Director, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

1. The surveyor observed that the elevator cab lights for the traction elevator were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32.

2. The surveyor observed that the patient room headwalls were not equipped with critical power receptacles to meet the requirements of NFPA-70, Section 517-18, and 517-19.

3. The surveyor observed that the panel identification and panel schedules were not accurate or were not updated to meet the requirements of NFPA-70, Section 110-22, and Section 384-13.

Based on random observation during the survey walk through while accompanied by the Plant Operations Director, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

1. The staff was unable to locate the med gas bonding to show that the requirements of NFPA-70, Section 250-104(c) were met.

Based on observation during the survey walk-through, not all interior finishes of rooms comply with applicable requirements of the Life Safety Code. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, because the lack of compliance can expose occupants to harmful fire and smoke conditions.

Findings include:

A. At 10:35am on 7/22/14 the Radiology #1 room and portions of the adjacent dressing room on the 1st floor were observed to have painted wood paneling wall finish to a height of 8' which could not be documented by staff at the time of the survey to meet the minimum finish rating requirements of Class A or Class B to comply with NFPA 101-2000, 19.3.3.2 (1) as an existing finish.

Based on observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 18.3.6.1. These deficiencies could affect all patients in the locations, as well as any staff and visitors present, because the lack of smoke detectors leaves the exit access corridors unprotected against early and prompt notification of a fire event that could render the exit access corridors unusable.

Findings include:

A. At 10:45am on 7/22/14 it was observed that the 1st floor Radiology reception office was considered to be located in the Emergency Department Addition sprinklered smoke compartment and was open to the corridor and indicated not to be staffed or observed on a 24/7 basis. The reception office area is not provided with smoke detection to comply with 18.3.6.1, Exception No. 1, (c).

B. At 10:46am on 7/22/14 it was observed that the 1st floor Radiology Waiting area adjacent the main lobby information/reception desk considered to be located in the Emergency Department Addition sprinklered smoke compartment was open to the corridor and was indicated not to be staffed or observed on a 24/7 basis. The waiting area ceiling cavity is not provided with smoke detection to comply with 18.3.6.1, Exception No. 2, (b).

Based on observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. At 2:00pm on 7/21/14 it was observed that the double egress doors at the entrance to the west wing Surgery Clinic suite has the south door equipped with manual flush bolts to permit securing of the suite doors after hours. The top flush bolt lever was damaged to prevent the full closure of the north door. Confirm that the south door is not also equipped with panic device hardware which would be inoperable when the manual flush bolts are engaged. The doors are not considered resistant to the passage of smoke to comply with 19.3.6.3.1 when not able to fully close. The flush bolt latching of the door prevents the intended operation of the panic device hardware on the door in noncompliance with 7.2.1.5.6.

B. At 2:15pm on 7/21/14 it was observed that the west wing former patient shower room was being used for storage of pharmacy supplies of combustible material/cardboard packaging. The room is less than 50 sf but constitutes a degree of hazard greater than that normal to the general occupancy due to the type and density of combustible materials. The room is not sprinklered or 1-hour enclosed to comply with 8.4.1.1. The room door contains a louver in non-compliance with 19.3.6.4 when the room is utilized for other than the shower function.

C. At 2:30pm on 7/21/14 it was observed that the corridor doors to the former OR suite area were equipped with manual flush bolts and panic hardware on the south door of the pair in noncompliance with 7.2.1.5.6. The panic device provides vertical rod latching of the door but is not required or permitted when used in combination with the manual flush bolts. The currently unoccupied area does not require both doors to be operational. The north door with the keyed latchset provides required ingress and egress from the space when the south door is secured with the flush bolts.

Based on observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.2.3. These deficiencies could affect all patients in the locations, as well as any staff and visitors present, because the lack of required protection can permit fire and smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. At 1:45pm on 7/21/14 it was observed that the 2nd floor former nurse station now used as a medication room contained a sliding pass-thru window. The smoke compartment is not sprinkler protected and the window system is not minimum 1/2-hour fire rated or resistant to the passage of smoke to comply with 19.3.6.2.1, 19.3.6.2.2 & 19.3.6.2.3.

B. At 2:15pm on 7/21/14 it was observed that the 2nd floor former nurse station along the corridor leading to the former surgery/delivery area contained a sliding pass-thru window constructed of wire glass in aluminum framing. The smoke compartment is not sprinkler protected and the window system is not minimum 1/2-hour fire rated or resistant to the passage of smoke to comply with 19.3.6.2.1, 19.3.6.2.2 & 19.3.6.2.3.

Based on random observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies that restrict the movement of smoke in accordance with 19.3.7.3 and 8.3.4.1. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

The finding is:

A. At 10:00am on 7/22/14 it was observed that the designated 1st floor smoke barrier wall indicated on the available Life Safety Plan passed through the rear door of the elevator near the center stair. The elevator doors do not comply with 8.3.4.1 relative to being resistant to the passage of smoke and do not remain closed upon activation of the elevator recall system.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with NFPA 101-2000, 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. At 1:15pm on 7/21/14 it was observed that the 2nd floor Soiled Utility room door (near room 209) was not self-closing to a latched condition to comply with NFPA 101-2000, 19.3.2.1 and 8.2.3.2.1.

B. At 1:20pm on 7/21/14 it was observed that the 2nd floor Pharmacy rooms containing storage of materials and supplies constituted a degree of hazard greater than that normal to the general occupancy. The room is not sprinklered or 1-hour enclosed to comply with 8.4.1.1. The corridor doors are not minimum 3/4-hour rated assemblies to comply with 19.3.2.1 and 8.2.3.2.3.1.

C. At 1:25pm on 7/21/14 it was observed that the 2nd floor Nurses' Storage room (across from the former Nurse Station now used as a Medication room) was not sprinklered or 1-hour enclosed to comply with 8.4.1.1. The corridor door was not a minimum 3/4-hour rated assembly to comply with 19.3.2.1 and 8.2.3.2.3.1.

D. At 1:30pm on 7/21/14 it was observed that the 2nd floor Cardio Storage room corridor door was not self-closing to a latched condition to comply with 19.3.2.1.

E. At 1:40pm on 7/21/14 it was observed that the 2nd floor "Chart room" record storage room was not sprinklered or 1-hour enclosed to comply with 8.4.1.1. The corridor door was not a minimum 3/4-hour rated self-closing assembly to comply with 19.3.2.1 and 8.2.3.2.3.1.

F. At 2:25pm on 7/21/14 it was observed that the 2nd floor Storage room near the former delivery room was not sprinklered or 1-hour enclosed to comply with 8.4.1.1. The corridor door was not a minimum 3/4-hour rated assembly to comply with 19.3.2.1 and 8.2.3.2.3.1.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with NFPA 101-2000, 18.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. At 11:00am on 7/22/14 it was observed that the 1st floor Soiled Utility room door in the Emergency Department Addition was not labeled as minimum 3/4-hour fire rated to comply with NFPA 101-2000, 18.3.2.1 and 8.2.3.2.1.

Based on observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating to comply with 19.3.1.1 and 8.2.5.2 and 7.1.3.2.1.(a) These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by compromising the required protection of the exit stair enclosure and preventing those occupants from reaching an exit from the building.

Findings include:

A. At 2:30pm on 7/21/14 it was observed that the fire rating label on the south exit stair enclosure (from the former surgery area) was 3/4-hour and not 1-hour rated to comply with 8.2.3.2.3.1.(b).

Based on 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:

A. At 9:00am on 7/22/14 it was observed that the exterior stair from the west wing exit discharge landing had a bottom riser greater than 3/16" difference from the remaining risers of the stair in non-compliance with 7.2.2.3.6.

B. At 9:05am on 7/22/14 it was observed that the exterior door from the west exit stair had an aluminum framing member below the threshold assembly. The height of the threshold was 1.5" above the stair landing surface in non-compliance with 7.2.1.3.

C. At 9:10am on 7/22/14 it was observed that the door at the basement level of the west exit stair had a direction of swing opposite to the direction of exit travel in non-compliance with 7.2.1.4.3.

D. At 9:45am on 7/22/14 it was observed that the 1st floor Maintenance Shop door from the designated exit passageway was not self-closing to a latched condition to comply with 7.1.3.2.1(c).

E. At 10:00am on 7/22/14 it was observed that the exterior stair from the east wing exit stair discharge lacked hand railings extending the full length of the stair treads and risers to comply with 7.2.2.4.3. The bottom tread was elevated above ground surface and was greater than 3/16" difference from remaining tread depths in non-compliance with 7.2.2.3.6.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress 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:

A. At 2:20pm on 7/21/14 it was observed that exit signs were not provided to identify the 2nd means of egress from the east-west corridor in the former surgery area on the 2nd floor to comply with 19.2.5.9.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 18/19.7.1.2. Drills were not conducted at least quarterly on each shift to familiarize facility personnel (nurses, interns, maintainance engineers, and adminsitrative staff) with the signals and emergency action as required under varied conditions.

Findings include:

A. Fire Drills conducted within the past year for the 2nd shift employees include the following dates and times:

2/24/14 at 1612 hours
5/21/14 at 1503 hours
11/26/13 at 1500 hours
8/21/13 at 1505 hours

The fire drills conducted during the last year for the 2nd shift employees had 3 of the last 4 drills occuring at approximately the same time and not at varing times during the normal work day. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. Fire drill records do not document that the fire alarm signal has been successfully transmitted to the monitoring agency during drill activities to comply with 18/19.7.2.2.

Based on random observation during the survey walk through while accompanied by the Plant Operations Director, the surveyor found that the fire alarm installation did not meet all of the requirements of NFPA-72. This could affect all occupants of the building if the fire alarm system did not operate properly during a fire emergency.

Findings include:

1. The surveyor observed that the unoccupied mechanical room near the ER housed a fire alarm NAC panel and was not equipped with a smoke detector to meet the requirements of NFPA-72, Section 1-5.6.

By direct observation the afternoon of 7/21/14 while in the company of the Plant Operation Director the surveyor finds:

A. Not all access and service openings for installed fire dampers, smoke dampers and fire /smoke dampers throughout the facility, are identified in the manner prescribed by NFPA 90A, 1999, 2-3.4.1 & 2-3.4.2. The service access is not identified with letters having a minimum height ½ inch to indicate the fire protection device within.

B. Documents for the inventory and inspection every 4 years were not provided for the fire dampers, smoke dampers & combination fire/smoke dampers. (NFPA 90A, 1999, 3-4.77)

Based on observation during the survey walk-through, not all Medical Gas storage locations comply with NFPA 99-1999, and NFPA 101-2000. This deficiency could affect all persons required to utilize the exit by preventing those occupants from safely reaching an area away from the building.


Findings include:

A. At 10:05am on 7/22/14 it was observed that oxygen tank storage location on the loading dock containing greater than 3000 cu. ft. of medical gas was not fully enclosed with 1-hour rated construction to separate the medical gas storage from the building exit discharge to comply with NFPA 99-1999, 4-3.1.1.2(2). The labeled fire door to the enclosure was not self-closing to comply with NFPA 101-2000, 8.2.3.2.1.

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 while accompanied by the Plant Operations Director, the surveyor found that not all testing requirements of NFPA-110 were met. This could effect all occupants of the building if the generator did not operate during a power outage.

Findings include:

1. The surveyor observed that the load on the generator during the monthly test did not meet the 30% requirement of NFPA-110, Section 6-4.2, and an annual load bank test was not conducted to meet the requirements of NFPA-110, Section 6-4.2.2.

Based on random observation during the survey walk through while accompanied by the Plant Operations Director, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

1. The surveyor observed that the elevator cab lights for the traction elevator were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32.

2. The surveyor observed that the patient room headwalls were not equipped with critical power receptacles to meet the requirements of NFPA-70, Section 517-18, and 517-19.

3. The surveyor observed that the panel identification and panel schedules were not accurate or were not updated to meet the requirements of NFPA-70, Section 110-22, and Section 384-13.

Based on random observation during the survey walk through while accompanied by the Plant Operations Director, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

1. The staff was unable to locate the med gas bonding to show that the requirements of NFPA-70, Section 250-104(c) were met.