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The facility did not ensure that emergency lighting of at least 1½-hour duration is provided, as required by " Life Safety Code " section #'s 7.9 & 19.2.9.1

a. On 10/07/14/12 at 2:00 PM, the surveyor was not provided with documentation from the Director of Engineering to indicate that the battery backup emergency lights were tested for 90 minutes annually at the CDP Building (153 Hazard Ave) as required by section #7.9 of the referenced " Life Safety Code " ; i.e. reports not obtained from property owner.

b. On 10/07/14/12 at 2:00 PM, the surveyor was not provided with documentation from the Director of Engineering to indicate that the battery backup emergency lights were inspected for 30 seconds a month at the CDP Building (153 Hazard Ave) as required by section #7.9 of the referenced " Life Safety Code " ;i.e. reports not obtained from property owner.

The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC.

On 10/07/14/12 at 11:00 AM, the surveyor was not provided with documentation from the Maintenance Technician to indicate that fire drills were held at unexpected times at the Johnson Surgery Center, as required by section # 21.7.2 of the " Life Safety Code " ; i.e. automated work order system directs maint tech to conduct drills within 10 days of alert-all drills done on 20th or 21st of each month.

The facility did not ensure that there is an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It is fully supervised. Required sprinkler systems are equipped with water flow and tamper switches, which are electrically connected to the building fire alarm system.

On 10/07/14 at 1:15 PM, the surveyor along with the Regional Director of Engineering observed that the sprinkler system water supply for the Main Campus from the fire pump had valves that were not supervised by the facility fire alarm and all valves lacked tags identifying there function as required.

The facility did not ensure that the facilities air conditioning and ventilation equipment was in accordance with NFPA 90A: Standard for the Installation of Air Conditioning and Ventilation Systems, NFPA 72 National Fire Alarm Code and as required by the referenced LSC.

On 10/08/14 at 10:30 AM, the surveyor was not provided with documentation from the Director of Engineering that indicated the smoke dampers and mechanical fire dampers identified as deficient or that had no access on the damper testing report were repaired and/or that the facility had an plan of correction in place to address the deficiencies as required.

1. K 130 Main Campus
The facility did not ensure that Emergency and Standby Power Systems were being installed, inspected and maintained as required in NFPA 110 "Standard for Emergency and Standby Power Systems" and NFPA 99 "Health Care Facilities".


On 10/07/14 at 1:00 PM, the surveyor along with the Director of Engineering observed that the facilities newly installed (12/2013) emergency generators were not secured to the concrete pad as required and the two housings identified as Generator 1 and Generator 2 lacked emergency shutdowns as required by section 3-5.5.6 Subsequent interview of the facility electrician identified that the facility was unable to ensure that the facility emergency electrical power was divided into three (3) separate and distinctive branches (1) Life Safety Branch, (2) Critical Branch and (3) Equipment Branch as required by NFPA 99 and NFPA 70, i.e. when interviewed the electrician was unable to tell me which transfer switch covered each branch and the transfer switches were not identified and no drawings were available.


2. K 130 Johnson Surgery Center
The facility did not ensure that Emergency and Standby Power Systems were being inspected and maintained as required in NFPA 110, " Standard for Emergency and Standby Power Systems ".


On 10/07/14 at 9:00 AM, the surveyor while accompanied by the Maintenance Technician observed that consideration was not given for the location of the temporary generator located at Johnson Surgery Center that minimized the possibility of damage from conditions such as vandalism, sabotage, and other similar occurrences, as required by section # 5-2 of NFPA 110, " Standard for Emergency and Standby Power Systems " .i.e. portable generator found to have access panels unlocked, wheels not chocked or secured, trailer tongue not locked or bollards installed.