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On 9/22-23/14, while accompanied by facility staff during the survey walk through of Center Building fire/smoke compartment, it was determined that the Fire Walls between building additions, floors and rooms contained unsealed penetrations in the 2-hour rated enclosures. These deficiencies could affect patients, as well as staff and visitors because the failure to provide properly maintain the barriers could result in smoke or fire passing from one building to another. Items observed include:

A. Wire and conduits are improperly firestopped around the outer edges and the interior space, where the wires pass through because it did not contain firestopping in accordance with NFPA 101, 8.2.3.2.4.2 locations include but not limited to:

1. 5th floor, East end above the 2 hour cross corridor doors, unsealed pipe penetration.

2. Corrected 04/02/2015.
3. Corrected 04/02/2015.
B. Corrected 04/02/2015.
C. Corrected 04/02/2015.

D. Floors 1-8, the designated 2-hour fire walls contain cross corridor doors which are located between Center Building and the East Building as well as between Center and the West building.

1. The hardware (knobs, plates, upper or lower rods, hinges, etc.) failed to contain any markings indicating the fire rating of the hardware. The hardware is not in accordance with NFPA 101, Section 8.2 and 19.1.2.3 and 7.2.1.7, NFPA 80, 1999 Edition Fire Doors and Windows.

2. Similar conditions wwere observed at doors to Exit Stair enclosures.

Based on random observation, with the EVS Manager, the surveyor finds that corridor doors lack positive latching hardware in accordance with 19.3.6.3.2. Failure to maintain corridor doors could allow a fire to spread beyond the room of fire origin.

Findings include:

A. Corrected 01/14/2016.

B. Corrected 04/02/2015.

C. Corrected 01/14/2016.

D. East Wing, 4th Floor, Microbiology and Parasitology Room

A. Corrected 04/02/2015.




14290


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

Findings include:

B. At 2:26 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the designated fire/smoke barrier wall between the Ground Floor Kitchen and Dishwashing Room is incomplete because an approximately 10'-0" section of wall, designated on the facility Life Safety Plans as a smoke barrier wall, does not exist.

A. 1. Corrected 04/02/2015.
2. Corrected 04/02/2015.

B. On 9/22/14 Center Building, observations determined that the 7th floor, Surgery Suite converted the " Cysto OR " into a storage room and it does not comply with the requirements for storage under NFPA 101, Chapter 19. The room is not rated, or provided with a self closing, positive latching door for storage rooms in excess of 100 square feet.

C. Corrected 04/02/2015.

D. Corrected 01/14/2016.

E. Corrected 04/02/2015.




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F. Corrected 04/02/2015.




16339


Based on random observation with the EVS Manager present, the surveyor observed that hazardous areas are not enclosed in accordance with 19.3.2.1. Lack of properly enclosure could result in an uncontrolled fire spreading beyond the room of fire origin and injuring staff and patients.

Findings include:

G. Hazardous areas were observed at which doors are not self-closing as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include:

1. Corrected 04/02/2015.

2. Corrected 01/14/2016.

3. Corrected 01/14/2016.

4. Corrected 04/02/2015.

5. Corrected 01/14/2016.

6. Corrected 04/02/2015.

Based on observations, the facility failed to provide exit components having a fire resistance rating of at least one hour ( 2 hour for buildings with more than 4 stories). The exit components are to be arranged to provide a path of escape, and to provide protection against fire or smoke from other parts of the building.

Findings include:

A. On 9/23/14, Center Building, Main floor, Exit Passageway serving Exit Stair #2. The passageway is equipped with ceiling tiles, above the ceiling is electrical conduit, plumbing, etc. that do not serve the exit passageway or stair and are not properly separated from the enclosure. NFPA 101, 19.3.1.1; 8.2.5.4(1) and 7.1.3.2.1(e).

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

A. While accompanied by the Director of Support Services and a Carpenter, the Surveyor observed the following deficiencies at Exit Stair 4:
1. Corrected 04/02/2015.


2. 1:13 PM September 23, 2014, Main Floor landing:
a. 4 conduits which do not serve the exit enclosure were observed within it as prohibited by 7.1.3.2.2.1(e).

b. The conduits noted in Item A.2.a. above were observed to not be firestopped at either the east or west walls of the enclosure as required by 8.2.3.2.4.2.
c. The west door to the exit enclosure was observed to not close to latch as required by 8.2.3.2.3.1. and NFPA 80 199 2-4.4.3.

B. 1. Corrected 04/02/2015.
2. a. Corrected 04/02/2015.
b. Corrected 04/02/2015.
C. Corrected 04/02/2015.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

A. Corrected 04/02/2015.
B. 1. Corrected 04/02/2015.
2. Corrected 04/02/2015.
C. Corrected 04/02/2015.
D. Corrected 04/02/2015.
E. At 1:40 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that the elevation of the walking surface at the West Wing exterior door from Exit Stair 5 is not maintained on the exterior side of the door for at least the width of the door as required by 7.2.1.3., because no stoop is provided.

F. At 1:41 PM on September 23, 2014, while accompanied by the Director of Support Services and a Carpenter, the Surveyor observed the drop-off at the West Wing Loading Dock is in excess of 30 inches and lacks a guard rail required by 7.2.2.4.1., because the existing guards were not in place.


16339

G. Corrected 04/02/2015.

Based on direct observation, the facility failed to provide illumination of exit discharges that would not be affected by the failure of a single bulb in accordance with NFPA 101, 39.2.8 and 7.8. This deficient practice could affect occupants utilizing the unlit egress path during an emergency.

A. On 9/23/14 it was observed that the rear exterior egress path did not contain a two-lamp light fixture. The existing fixture was deficient per NFPA 101, Section 7.8.1.4, in only providing a one-lamp fixture at the exit discharge.

Based on interviews, the facility failed to provide proper maintenance, inspections and testing for emergency lights used within the facility in accordance with NFPA 101 Sections 7.9.2 . The facility is required to provide monthly and annual timed inspections with documentation in written logs for all emergency battery-pack light fixtures and operable units with charged batteries. This deficient practice could affect staff and patients, if the lights failed and prolonged the evacuation in an emergency situation.

Findings include:

A. On 9/23/14, During the interview the surveyors were informed that they had not conducted the required 30-second monthly tests or an annual 90-minute test, per NFPA 101, Section 7.9.3.

1. No "30-second monthly test" Per NFPA 101, Section 7.9.3.

2. No "90-minute annual test" Per NFPA 101, Section 7.9.3.

Based on random observation during the survey walk-through, staff interview, and document review, not all emergency lighting is maintained in accordance with 7.9. These deficiencies could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

A. While accompanied by the Director of Support Services and a Carpenter, the Surveyor observed that exterior egress paths are not illuminated by emergency lighting as required by 7.8.1.3. and 7..8.1.4. Locations observed include:
1. 1:35 PM September 23, 2014: The door from Exit Stair 4.
2. 1:40 PM September 23, 2014: The door from Exit Stair 5.

B. Corrected 01/14/2016.
C. During a review of the facility's building systems test records, it was determined that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3. During an interview held in the West Wing Seventh Floor Conference Room at 9:31 AM on September 24, 2014, the provider's Director of Support Services confirmed this finding.

Based on direct observation and interview, the facility failed to provide and maintain a "complete fire alarm system" in accordance with NFPA 101, 2000 Edition, Sections 4.2 and 9.6 as well as NFPA 70 and NFPA 72, Section 1-5.6. This deficient practice could affect all staff and visitors.

Findings include:

A. On 9/23/14 during interviews with facility representatives, it was determined that the smoke detectors and pull stations are not being inspected. It is unclear how the system is installed or if the system is functional.

1. lity does not maintain as-built drawings, Operation and Maintenance manuals, or operational sequence documentation per NFPA 72 1999 7-5.1.

2. Facility does not conduct periodic visual inspections of system per NFPA 72 1999 Table 7-3.1.

3. Facility does not conduct periodic tests of system components NFPA 72 1999 Table 7-3.2.

Based on fire alarm interview, the facility failed to properly test the fire alarm system in accordance with NFPA 101, 2000 Edition, Sections 4.2 and 9.6 as well as NFPA 70 and NFPA 72. This deficient practice could affect an indeterminable number of staff and visitors.

Finding include:

On 9/23/14 during interviews with facility representatives, it was determined that the smoke detectors and pull stations are not being inspected. It is unclear how the system works or if the system is functional.

A. Functional Test: Tests to be conducted on each individual smoke detector with specific information logged such as "Individual Addresses", "Manufacture's Range", "Activation Point" and "Pass/Fail".

B. Sensitivity Test: no Sensitivity Test was performed on all smoke detectors in the past 2-years. This test includes the "Manufacture's Range for each tested device.

On 9/22-23/14 observations during the walk through, the facility failed have all sprinklers installed to meet the requirements of NFPA 101, 2000 Edition, Sections 19.3.5; NFPA 13, 1999 Edition. This deficient practice would affect an indeterminable number of staff , visitors and patients, if the sprinklers failed to operate properly in the event of a fire due to improper installation.

Findings Include:

A. Corrected 04/02/2015.
B. Corrected 04/02/2015.
C. Corrected 04/02/2015.


D. Corrected 01/14/2016.

E. Corrected 01/14/2016.


16339


Based on random observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

F. East Wing, 6th Floor: While accompanied by the provider's EVS Manager, the skylight in the Conference Room was observed that lack sprinkler coverage required by NFPA 13 1999 5-1.1.(1).

G. East Wing, 3rd Floor Radiology Department - Electrical Room / Closet between Men and Women's Gowning Room lack sprinkler protection to comply with NFPA 13 1999 5-1.1.(1).

H. 1. Corrected 04/02/2015.
2. Corrected 04/02/2015.
3. Corrected 04/02/2015.
4. Corrected 04/02/2015.
5. Corrected 04/02/2015.

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 document review and staff interview, the emergency generator is not inspected and tested in accordance with NFPA 99. These deficiencies could affect any patients, staff, or visitors in the building because the emergency generator could fail to operate under emergency conditions.

Findings include:

A. Corrected 04/02/2015.
B. Corrected 04/02/2015.
C. During the document review process, it was determined that the emergency generator is not tested under load for 30 minutes each month, as required by NFPA 99 1999 3-4.4.1.1. and NFPA 110 6-4.2., between January 1, 2014 and May 31, 2014. This determination was confirmed by the provider's Director of Support Services during an interview held in the West wing Seventh Floor Conference Room at 9:41 AM September 24, 2014.

Surveyor #31586
New deficiency cited at LSC survey on 01/14/2016

D. On 01/14/2016 at 9:50 AM during document review and staff interview it was determined that the facilities emergency generator has not been tested monthly for the required 30-minutes under 30% loading conditions. The facility has installed a temporary generator to meet the testing requirements.

Based on observations, the facility failed to install electrical wiring in accordance with NFPA 101, 2000 Edition, Section 9.1.2 and NFPA 70, 1999 Edition, National Electrical Code. This deficient practice could affect an indeterminable number of staff and patients that would come in contact with deficient electrical wiring.

Finding include:

A. 7th floor Center Building, Surgery Suite, does not contain normal power outlets. This does not meet with NFPA 70 (1999) 517-19.




14416


By direct observation and staff interview while in the company of the Facility ' s Director of Support Services and Stationary Engineer the Surveyor finds the facility does not have a compliant Type 1 Essential Electrical System. (NFPA 99, 1999, 3-4)
Observations and staff interview include but not limited to:
a. There are automatic transfer switches installed and identified for the Life Safety Branch, Critical Branch and Equipment Branch.
b. Identification of the distribution and separation for the three required branches is not provided at circuit panel locations throughout the facility.
c. Interview with the Director of Support Service and Stationary Engineer indicated that when the emergency generator is supplying electricity to the facility during a utility outage the entire facility has electrical power not just the Essential Electrical System distribution within the facility. Only those electrical loads as identified in NFPA 99, 1999, 3-4.2.2.1 shall be supported of a Type 1 Essential Electrical System.