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A. Based upon random observation, document review (and the lack of documentation) and based upon interview of the Director of Facilities on May 21, 2013 and May 22, 2013, the surveyor finds that the East Building, the Center Building and the West Building are constructed with reinforced concrete structural systems. However, the provider lacks historical data, U L Design Numbers, and or other information which identifies the Construction Type of each Building as defined by NFPA 220. The provider is not able to demonstrate that each of the three buildings is at least Type II (222) construction, if not Type I (332) construction in accordance with 19.1.6.2.

B. Basement Level Center Building: The Bed Storage/Furniture Storage Room is ribbed slab concrete construction above with a monolithic plaster ceiling installed on the bottom of the concrete. This plaster ceiling has large voids in it. The provider lacks documentation that demonstrates how the floor assembly it at least two hour rated without the plaster ceiling.

NEW 08/20/14: The plaster ceiling identified in Item B. above was observed to have been patched.

A. Based upon random observation, document review (and the lack of documentation) and based upon interview of the Director of Facilities on May 21, 2013 and May 22, 2013, the surveyor finds that the East Building, the Center Building and the West Building are constructed with reinforced concrete structural systems. However, the provider lacks historical data, U L Design Numbers, and/or other information which identifies the Construction Type of each Building as defined by NFPA 220. The provider is not able to demonstrate that each of the three buildings is at least Type II (222) construction, if not Type I (332) construction in accordance with 19.1.6.2.

Based on random observation during the survey walk-through while accompanied by the senior director of facilities management, the surveyor found that 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 by the loss of a single transfer switch.


Findings include:

1. Distribution panel EMDP, (the life safety distribution panel), is serving isolation panels IP1, IP2, and IP3 which are required by NFPA-70, Section 517-33, to be served by the critical branch of the emergency power system. Each branch of the emergency electrical system served by this generator shall be served from its' own transfer switch to meet the requirements of NFPA-70, Section 517-30.

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

Findings include:

1. Normal power receptacles were not provided in the c-section rooms, and the nursery 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.

2. Receptacles in the c-section room and nursery area need to be labeled with the circuit number and panelboard supplying them in accordance with NFPA-70, Section 517-19.

3. Critical receptacles are not provided in general care rooms in accordance with NFPA-70, Section 517-18.

4. Corrected 4/17/14

5. Corrected 4/17/14