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Based on observation during the survey walk-through, not all exit access corridors are separated from use areas to comply with 19.3.6.1. These deficiencies could affect all patients in the locations, as well as any staff and visitors present, because the lack of smoke tight walls 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. In the afternoon of 11/19/2014 Third floor A-Wing, former bathroom within the nurse station contains a hole in the wall adjacent to plumbing pipe penetrations (former lav)which leaves this wall open to the passage of fire/smoke and renders the nurse station and corridor open to the passage of fire/smoke. The lack of a fire/smoke tight wall does not comply with 19.3.6.2.2

During the survey walk-through, accompanied by facility staff, it was observed that not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could compromise the use of the exit access corridor during a fire/smoke event.

Findings include:

A. In the morning of 11/19/2014, on the fourth floor next to Room 401, it was observed that the corridor doors at the supply closet do not have positive latching as required by 19.3.6.3.2.

Based on random observation during the survey walk through it was observed that a continuous protected path to the outside is not provided in order to comply with 19.3.1.1. This deficiency could affect the slowing of a fire, smoke and heat between compartments.
The finding includes:

A. In the afternoon of 11/18/2014 Fiifht floor B-Wing not all components of a shaft enclosure are provided with elements which maintain the fire resistant rating of the enclosure.

1. B- Wing Stair adjacent to the horizontal exit.Surveyor observed stair door hardware components which contained an aluminum knob.

2. In the morning of 11/19/2014 Third floor A-Wing Kitchen the north wall contains an access panel to a vertical chase. Conduit were observed through the floor to an open junction box.

During the survey walk-through, accompanied by facility staff, it was observed that not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2. These deficiencies could affect all patients, staff, and visitors within the smoke compartment of the location by allowing smoke and fire to escape from hazardous rooms into the exit access corridor.

Findings include:

A. In the morning of 11/19/2014 in the basement of B Wing, the B Mechanical Room has an unprotected penetration in the corridor wall near the door.


B. In the afternoon of 11/19/2014 third floor, A-Wing, the Soiled Utility room (deemed hazardous) lacks a self closing door.


C. In the afternoon of 11/18/2014 fifth floor, B-Wing, the equipment storage room (formerly shower room - and deemed a hazardous room on the facility life safety plan) lacks a self closing door.

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 attempting to use the egress paths because the paths could become restricted.

Findings include:

A. In the afternoon of 11/18/2014, the following conditions were observed at the Fifth Floor Center "angled" wall adjacent to the Center Elevator and the Center West Exit Stair:

1. The clear width of the Corridor on both sides of the angled wall was observed to be reduced, as compared to corridor widths at either end of the wall. The angled wall is thus not arranged to avoid an obstruction to the convenient removal of building occupants to comply with 19.2.3.3.

2. The door in the angled wall, when in the open (90 degree) position was observed to reduce the Corridor to less than half its required width which does not comply with 7.2.1.4.4.



32979


During the survey walk-through, accompanied by facility staff, it was observed that exit access is not arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the building.

Findings include:

B. In the morning of 11/19/2014, on the fourth floor in the O.R. Suite, it was observed that an exit access door from the surgical area is equipped with a keyed deadbolt and a lockset, thus requiring more than one than one operation to open the door. 7.2.1.5.4

C. In the morning of 11/19/2014, in the basement Pharmacy, the exit access doors from the Pharmacy were observed to be equipped with multiple locks and latches, thus requiring more than one than one operation to open the doors. 7.2.1.5.4

During the survey walk-through, accompanied by facility staff, it was observed that the facility failed to provide suites that comply with 19.2.5 concerning travel distance to exit access doors. This condition may affect patients, staff and visitors during a fire emergency by increasing the amount of time and travel distance required to reach an exit access corridor.

Findings include:

A. In the morning of 11/19/2014, on the fourth floor at the O.R. Suite identified on Life Safety drawings dated 10/1/2013 it was observed that egress from the most remote point of the med room located within the PACU area requires travel through two intervening rooms and has a travel distance to an exit access door exceeding the 50 feet permitted by 19.2.5.8. As measured on the 10/1/2013 Life Safety drawing the travel distance is approximately 85 feet.

During the survey walk-through, accompanied by facility staff, it was observed that paths of egress are not identified by exit signage in accordance with 19.2.10.1 and 7.10. These deficiencies could affect all patients, staff, and visitors in the areas described by preventing those occupants from readily identifying
the path of egress.

Findings include:

A. In the afternoon of 11/18/2014, on the fifth floor, conflicting signage reading " Stairs " , " Not An Exit " , and " Emergency Exit " were observed on the door of the North B Wing stair. Facility staff removed the " Not An Exit " signage during the survey walk through. 19.2.10.1, 7.10

B. In the afternoon of 11/18/2014 and morning of 11/19/2014, on the fifth, fourth, and second floors of the Pavilion Wing, the door to the northwest stair was observed to be provided with signage reading " Stairs " and " Not An Exit. " This stair is identified as an exit stair on the Life Safety drawings, dated 10/1/2013, and is provided with an exit passageway to the exit discharge on the first floor. During staff interview it could not be determined whether this stair is a required exit or not.

C. In the morning of 11/19/2014, in the basement of the Pavilion Wing, it was observed that the exit access corridor door at the Boiler Room is not provided with exit signage. 19.2.10.1, 7.10

Based on random observation during the survey walk through on the morning of 11/19/2014, while accompanied by the electrical technician, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:


A. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7.

B. The fire pump was not equipped with a transfer switch at the fire pump location and was not served from the emergency generator to comply with NFPA-20, Section 6.2.

A. The morning of 11/18/14 during document review in the company of the Corporate Director of Plant Operations and the Hospital ' s Director of Plant Operations the surveyor finds, the fire/smoke damper inventory and inspection dated 2010, that dampers which were found deficient and had failed testing were not identified as being corrected.


20224

Ventilation systems are not maintained in accordance with applicable standards.

Findings include

B In the afternoon of 11/18/2014 the surveyor did not find the installation of fire dampers for the duct penetrations into vertical shaft installations. Through staff interview it was determined that fire dampers and protections are not provided for the duct penetrations of supply and return/exhaust ventilation systems to comply with NFPA 90A, 1999, 3-3.2

Locations observed:

1. Fifth floor Kitchen B-Wing
2. Third floor Kitchen A-Wing
3. First floor Waiting room B-Wing (near the Emergency Department suite)

Based on random observation during the survey walk-through and staff interview, 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.

Findings include:

A. In the morning of 11/19/2014: Fifth floor, Pavilion Wing, North/South corridor adjacent to restraint and quiet room contained four chairs lined up along the east wall outside of a psychiatrist office. These chairs form an obstruction within a means of egress corridor which does not comply with 19.2.3.3. and 7.1.10.2.1. During an interview held at that time, the provider's representative stated that patients typically use those chairs while waiting to see the psychiatrist within the office. This deficiency could affect patients and staff within two wings because their ability to reach an exit under emergency conditions would be compromised.

A. Emergency Department:

Based on direct observation, the afternoon on the afternoon of 11/19/2014 while in the company of the Maintenance Technician, the surveyor finds the facility failed to provide:

1. Separation by an intervening wall the medical gas zone valves and the outlets/inlets they serve for treatment bays 1 thru 6. (NFPA 99, 1999, 4-3.1.2.3 (d)

2. Zone valves for the outlets /inlets in Triage. (NFPA 99, 1999, 4-3.1.2.3 (d)

Based on random observation during the survey walk-through not all medical gas systems comply with NFPA 99, 1999, Chapter 4. Failure to install and maintained medical gas systems in accordance with referenced standard could result in failure of those systems, while in use or needed for critical patients.

The findings are:

A. On the afternoon of 03/19/13 the 4th floor Surgery area medical gas systems contained a master zone shut off valve located behind a lockable door and within an office. This location does not comply with NFPA 99 1999 chapter 4 for the required access to the shut off valve.

B. On the afternoon of 03/19/13 the 4th floor Operating rooms 1, 2, 3 and 4 each lacked a medical gas shut off valve. The surveyor was informed that the only shut off valve is the master located within the office. Therefore, under emergency conditions an individual Operating room cannot be shut down without shutting down all Operating rooms. This application does not comply with NFPA 99 1999 chapter 4.

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, while accompanied by the electrical technician, the surveyor observed 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. On the afternoon of 11/19/2014, the surveyor observed that the emergency power panels are not properly separated into the life safety, the critical and the equipment branches as required by NFPA-70, Section 517-31 thru 35. The system one line diagram was not up to date and it did not show all emergency panels or what branch each transfer switch served, and most panels were not labeled with the branch of emergency power they served. Examples include:

1. On the morning of 11/19/2014, the surveyor observed that panel E5PH is serving a mixture of all three branches, life safety, critical and equipment.

2. On the morning of 11/19/2014, the surveyor observed that panel ETS01-5 serves a mixture of life safety and critical, including room receptacles (critical) Section 517-33, and elevator cab lighting that shall be served from life safety in accordance with section 517-32.

3. On the morning of 11/19/2014, the surveyor observed that panels CP2 and CP3 are new critical panels in the remodeled northeast wings on the second and third floors, and they are serving med gas alarms and emergency lighting which shall be served by the life safety panel to comply with Section 517-32.

4. On the morning of 11/19/2014, the surveyor observed that panel E2PA did not have enough detail in the circuit description to determine if it was life safety or critical.

5. On the morning of 11/19/2014, the surveyor observed that panel EBPA serves a mixture of life safety and equipment.

6. On the morning of 11/19/2014, the surveyor observed that two panels in the tunnel off of mechanical room B, EBPN and EBPO were labeled as critical panels , but served mostly equipment loads.

Based on random observation during the survey walk-through while accompanied by the electrical technician the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

A. On the morning of 11/19/2014, the surveyor observed that normal power receptacles were not provided in operating rooms on the fourth floor as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

B. On the morning of 11/19/2014, the surveyor observed that bonding of the piping for the gas system could not be located by staff as required by NFPA-70, Section 250-104(b). This could cause a potential difference between gas piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

C. On the morning of 11/19/2014, the surveyor observed that patient bed location on the third floor in wing A were not equipped with emergency receptacles as required by NFPA-70, Section 517-18. This could effect any patient in this wing in the event of a power outage.

D. On the morning of 11/19/2014, the surveyor observed that panels in several location, including panels 5JP, 5PG, E4PK, E2PA, and several other locations, were either missing schedules or the schedules needed to be updated to comply with NFPA-70, Section 110-22. Schedules were handwritten, breakers were on but marked as spares or not labeled at all, and some panels including the panel at the 24 hour security desk and the emergency panel in the mechanical room 4 were not identified.

Based on random observation during the survey walk-through on the morning of 11/19/2014, while accompanied by the electrical technician the surveyor found that portions of the elevator control system are not installed in accordance with NFPA-70, and ASME A17.1. Any elevator user could be put in a dangerous situation without the proper safety devices installed.

Findings include:

A. On the morning of 11/19/2014, the surveyor observed that each elevator was not equipped with a single lockable disconnect or proper labeling for the emergency lighting, receptacle, and ventilation as required by NFPA-70, Section 620-53.

B. On the morning of 11/19/2014, the surveyor observed that the disconnect for the emergency lighting and controls for each elevator was not fed from the life safety panel in accordance with NFPA-70, Section 517-32(f).

Based on observation during the survey walk-through, not all exit access corridors are separated from use areas to comply with 19.3.6.1. These deficiencies could affect all patients in the locations, as well as any staff and visitors present, because the lack of smoke tight walls 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. In the afternoon of 11/19/2014 Third floor A-Wing, former bathroom within the nurse station contains a hole in the wall adjacent to plumbing pipe penetrations (former lav)which leaves this wall open to the passage of fire/smoke and renders the nurse station and corridor open to the passage of fire/smoke. The lack of a fire/smoke tight wall does not comply with 19.3.6.2.2

During the survey walk-through, accompanied by facility staff, it was observed that not all doors in exit access corridors are in compliance with 19.3.6.3. This deficiency could compromise the use of the exit access corridor during a fire/smoke event.

Findings include:

A. In the morning of 11/19/2014, on the fourth floor next to Room 401, it was observed that the corridor doors at the supply closet do not have positive latching as required by 19.3.6.3.2.

Based on random observation during the survey walk through it was observed that a continuous protected path to the outside is not provided in order to comply with 19.3.1.1. This deficiency could affect the slowing of a fire, smoke and heat between compartments.
The finding includes:

A. In the afternoon of 11/18/2014 Fiifht floor B-Wing not all components of a shaft enclosure are provided with elements which maintain the fire resistant rating of the enclosure.

1. B- Wing Stair adjacent to the horizontal exit.Surveyor observed stair door hardware components which contained an aluminum knob.

2. In the morning of 11/19/2014 Third floor A-Wing Kitchen the north wall contains an access panel to a vertical chase. Conduit were observed through the floor to an open junction box.

During the survey walk-through, accompanied by facility staff, it was observed that not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2. These deficiencies could affect all patients, staff, and visitors within the smoke compartment of the location by allowing smoke and fire to escape from hazardous rooms into the exit access corridor.

Findings include:

A. In the morning of 11/19/2014 in the basement of B Wing, the B Mechanical Room has an unprotected penetration in the corridor wall near the door.


B. In the afternoon of 11/19/2014 third floor, A-Wing, the Soiled Utility room (deemed hazardous) lacks a self closing door.


C. In the afternoon of 11/18/2014 fifth floor, B-Wing, the equipment storage room (formerly shower room - and deemed a hazardous room on the facility life safety plan) lacks a self closing door.

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 attempting to use the egress paths because the paths could become restricted.

Findings include:

A. In the afternoon of 11/18/2014, the following conditions were observed at the Fifth Floor Center "angled" wall adjacent to the Center Elevator and the Center West Exit Stair:

1. The clear width of the Corridor on both sides of the angled wall was observed to be reduced, as compared to corridor widths at either end of the wall. The angled wall is thus not arranged to avoid an obstruction to the convenient removal of building occupants to comply with 19.2.3.3.

2. The door in the angled wall, when in the open (90 degree) position was observed to reduce the Corridor to less than half its required width which does not comply with 7.2.1.4.4.



32979


During the survey walk-through, accompanied by facility staff, it was observed that exit access is not arranged so that exits are readily accessible at all times in accordance with 19.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the building.

Findings include:

B. In the morning of 11/19/2014, on the fourth floor in the O.R. Suite, it was observed that an exit access door from the surgical area is equipped with a keyed deadbolt and a lockset, thus requiring more than one than one operation to open the door. 7.2.1.5.4

C. In the morning of 11/19/2014, in the basement Pharmacy, the exit access doors from the Pharmacy were observed to be equipped with multiple locks and latches, thus requiring more than one than one operation to open the doors. 7.2.1.5.4

During the survey walk-through, accompanied by facility staff, it was observed that the facility failed to provide suites that comply with 19.2.5 concerning travel distance to exit access doors. This condition may affect patients, staff and visitors during a fire emergency by increasing the amount of time and travel distance required to reach an exit access corridor.

Findings include:

A. In the morning of 11/19/2014, on the fourth floor at the O.R. Suite identified on Life Safety drawings dated 10/1/2013 it was observed that egress from the most remote point of the med room located within the PACU area requires travel through two intervening rooms and has a travel distance to an exit access door exceeding the 50 feet permitted by 19.2.5.8. As measured on the 10/1/2013 Life Safety drawing the travel distance is approximately 85 feet.

During the survey walk-through, accompanied by facility staff, it was observed that paths of egress are not identified by exit signage in accordance with 19.2.10.1 and 7.10. These deficiencies could affect all patients, staff, and visitors in the areas described by preventing those occupants from readily identifying
the path of egress.

Findings include:

A. In the afternoon of 11/18/2014, on the fifth floor, conflicting signage reading " Stairs " , " Not An Exit " , and " Emergency Exit " were observed on the door of the North B Wing stair. Facility staff removed the " Not An Exit " signage during the survey walk through. 19.2.10.1, 7.10

B. In the afternoon of 11/18/2014 and morning of 11/19/2014, on the fifth, fourth, and second floors of the Pavilion Wing, the door to the northwest stair was observed to be provided with signage reading " Stairs " and " Not An Exit. " This stair is identified as an exit stair on the Life Safety drawings, dated 10/1/2013, and is provided with an exit passageway to the exit discharge on the first floor. During staff interview it could not be determined whether this stair is a required exit or not.

C. In the morning of 11/19/2014, in the basement of the Pavilion Wing, it was observed that the exit access corridor door at the Boiler Room is not provided with exit signage. 19.2.10.1, 7.10

Based on random observation during the survey walk through on the morning of 11/19/2014, while accompanied by the electrical technician, not all portions of the sprinkler system are installed in accordance with NFPA-13 (1999). This could effect the safety of all occupants of the building if the sprinkler system did not operate as required during a fire.

Findings include:


A. The fire pump remote alarm panel does not have the four alarm points required by NFPA 20-7-4.7.

B. The fire pump was not equipped with a transfer switch at the fire pump location and was not served from the emergency generator to comply with NFPA-20, Section 6.2.

A. The morning of 11/18/14 during document review in the company of the Corporate Director of Plant Operations and the Hospital ' s Director of Plant Operations the surveyor finds, the fire/smoke damper inventory and inspection dated 2010, that dampers which were found deficient and had failed testing were not identified as being corrected.


20224

Ventilation systems are not maintained in accordance with applicable standards.

Findings include

B In the afternoon of 11/18/2014 the surveyor did not find the installation of fire dampers for the duct penetrations into vertical shaft installations. Through staff interview it was determined that fire dampers and protections are not provided for the duct penetrations of supply and return/exhaust ventilation systems to comply with NFPA 90A, 1999, 3-3.2

Locations observed:

1. Fifth floor Kitchen B-Wing
2. Third floor Kitchen A-Wing
3. First floor Waiting room B-Wing (near the Emergency Department suite)

Based on random observation during the survey walk-through and staff interview, 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.

Findings include:

A. In the morning of 11/19/2014: Fifth floor, Pavilion Wing, North/South corridor adjacent to restraint and quiet room contained four chairs lined up along the east wall outside of a psychiatrist office. These chairs form an obstruction within a means of egress corridor which does not comply with 19.2.3.3. and 7.1.10.2.1. During an interview held at that time, the provider's representative stated that patients typically use those chairs while waiting to see the psychiatrist within the office. This deficiency could affect patients and staff within two wings because their ability to reach an exit under emergency conditions would be compromised.

A. Emergency Department:

Based on direct observation, the afternoon on the afternoon of 11/19/2014 while in the company of the Maintenance Technician, the surveyor finds the facility failed to provide:

1. Separation by an intervening wall the medical gas zone valves and the outlets/inlets they serve for treatment bays 1 thru 6. (NFPA 99, 1999, 4-3.1.2.3 (d)

2. Zone valves for the outlets /inlets in Triage. (NFPA 99, 1999, 4-3.1.2.3 (d)

Based on random observation during the survey walk-through not all medical gas systems comply with NFPA 99, 1999, Chapter 4. Failure to install and maintained medical gas systems in accordance with referenced standard could result in failure of those systems, while in use or needed for critical patients.

The findings are:

A. On the afternoon of 03/19/13 the 4th floor Surgery area medical gas systems contained a master zone shut off valve located behind a lockable door and within an office. This location does not comply with NFPA 99 1999 chapter 4 for the required access to the shut off valve.

B. On the afternoon of 03/19/13 the 4th floor Operating rooms 1, 2, 3 and 4 each lacked a medical gas shut off valve. The surveyor was informed that the only shut off valve is the master located within the office. Therefore, under emergency conditions an individual Operating room cannot be shut down without shutting down all Operating rooms. This application does not comply with NFPA 99 1999 chapter 4.

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, while accompanied by the electrical technician, the surveyor observed 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. On the afternoon of 11/19/2014, the surveyor observed that the emergency power panels are not properly separated into the life safety, the critical and the equipment branches as required by NFPA-70, Section 517-31 thru 35. The system one line diagram was not up to date and it did not show all emergency panels or what branch each transfer switch served, and most panels were not labeled with the branch of emergency power they served. Examples include:

1. On the morning of 11/19/2014, the surveyor observed that panel E5PH is serving a mixture of all three branches, life safety, critical and equipment.

2. On the morning of 11/19/2014, the surveyor observed that panel ETS01-5 serves a mixture of life safety and critical, including room receptacles (critical) Section 517-33, and elevator cab lighting that shall be served from life safety in accordance with section 517-32.

3. On the morning of 11/19/2014, the surveyor observed that panels CP2 and CP3 are new critical panels in the remodeled northeast wings on the second and third floors, and they are serving med gas alarms and emergency lighting which shall be served by the life safety panel to comply with Section 517-32.

4. On the morning of 11/19/2014, the surveyor observed that panel E2PA did not have enough detail in the circuit description to determine if it was life safety or critical.

5. On the morning of 11/19/2014, the surveyor observed that panel EBPA serves a mixture of life safety and equipment.

6. On the morning of 11/19/2014, the surveyor observed that two panels in the tunnel off of mechanical room B, EBPN and EBPO were labeled as critical panels , but served mostly equipment loads.

Based on random observation during the survey walk-through while accompanied by the electrical technician the surveyor found that not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

A. On the morning of 11/19/2014, the surveyor observed that normal power receptacles were not provided in operating rooms on the fourth floor as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

B. On the morning of 11/19/2014, the surveyor observed that bonding of the piping for the gas system could not be located by staff as required by NFPA-70, Section 250-104(b). This could cause a potential difference between gas piping and other grounded metal surfaces which would create a shock hazard for staff and patients.

C. On the morning of 11/19/2014, the surveyor observed that patient bed location on the third floor in wing A were not equipped with emergency receptacles as required by NFPA-70, Section 517-18. This could effect any patient in this wing in the event of a power outage.

D. On the morning of 11/19/2014, the surveyor observed that panels in several location, including panels 5JP, 5PG, E4PK, E2PA, and several other locations, were either missing schedules or the schedules needed to be updated to comply with NFPA-70, Section 110-22. Schedules were handwritten, breakers were on but marked as spares or not labeled at all, and some panels including the panel at the 24 hour security desk and the emergency panel in the mechanical room 4 were not identified.