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Based on an observation, it was determined that a section of the facility corridor wall failed to act as the smoke barrier, to meet the required 30-minute rating, for the exit egress path. This deficient practice could affect patients, staff and visitors if smoke was to transfer into the egress path.

Findings include:

1. On 5/14/14 while accompanied by Facility Representatives it was determined that in the basement, cafeteria, wall separating the kitchen from the cafeteria contained 3 sets of transfer grills that would not resist the passage of smoke. This does not comply with NFPA 101, Section 19.3.6.2.2 and 8.2.4.4.

Based on an observation it was determined that the facility failed to maintain the closure of the corridor doors per CMS. This deficient practice could affect patients, staff and visitors if a fire would start in this area. Corridor doors opening onto an exit corridor would not provide a proper smoke barrier during a fire emergency.

Findings include:

1. On 5/14/14 while accompanied by Facility Representatives it was determined that in the basement exit corridor leading to the cafeteria contained a set of double doors into a training room. The doors were not installed with positive latching hardware and the inactive door leaf was installed with manual flush bolts that would require constant monitoring to comply with the latching requirement. This does not comply with NFPA 101, Section 19.3.6.3.2 and SOM, Appendix I, Task 4.

2. On 5/13/14 while accompanied by Facility Representatives it was determined that on the 2nd floor, LDR suite contained a set of double doors on the east side of the suite. An observation determined that the north door leaf did not latch to the frame during fire alarm testing. This does not comply with NFPA 101, Section 19.3.6.3.2.

Based on observations of a hazardous area and interviews, the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

1. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 9th floor, room 923 is being used as a storage room and the door is not equipped with a door closer. All doors and frames protecting storage rooms located in non-sprinkler protected areas/zones are to be rated for a minimum of 1-hour. This is not per NFPA 101, section 19.3.2.1.

2. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 9th floor, room 923B is being used as a storage room and the door is not equipped with a door closer. All doors and frames protecting storage rooms located in non-sprinkler protected areas/zones are to be rated for a minimum of 1-hour. This is not per NFPA 101, section 19.3.2.1.

3. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 9th floor, room 929 is being used as a storage room and the door closer installed was not properly connected and did not close the door to the frame when tested. All doors and frames protecting storage rooms located in non-sprinkler protected areas/zones are to be rated for a minimum of 1-hour. This is not per NFPA 101, section 19.3.2.1.

4. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 9th floor, room 931 is being used as a storage room and the door closer installed was not properly connected and did not close the door to the frame when tested. All doors and frames protecting storage rooms located in non-sprinkler protected areas/zones are to be rated for a minimum of 1-hour. This is not per NFPA 101, section 19.3.2.1.

5. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 8th floor, room 823 is being used as a storage room and the door is not equipped with a door closer. All doors and frames protecting storage rooms located in non-sprinkler protected areas/zones are to be rated for a minimum of 1-hour. This is not per NFPA 101, section 19.3.2.1.

6. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 6th floor, Storage Room doors are not equipped with door closers. All doors and frames protecting storage rooms located in non-sprinkler protected areas/zones are to be rated for a minimum of 1-hour. This is not per NFPA 101, section 19.3.2.1.

7. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " E " Building on the 4th floor, Clean Utility Room door to the corridor did not latch to the door frame when tested. This is not per NFPA 101, section 19.3.2.1.

8. On 5/13/14 while accompanied by Facility Representatives an observation determined that in the " B " Building on the 1st floor, Storage Room adjacent to Stair to basement and B111 was not installed with a door closer. This is not per NFPA 101, section 19.3.2.1.

9. On 5/14/14 while accompanied by Facility Representatives an observation determined that in the " D " Building, Basement, Kitchen contained 2 doors that opened into the cafeteria and exit path that were not installed with proper latching door hardware. This is not per NFPA 101, section 19.3.2.1.

Based on observations it was determined that the facility did not provide exits with properly configured stair components or prohibited the use of these space from alternate activities. This deficient practice could affect patients, staff and visitors, by preventing those occupants from reaching an exit discharge from the building due to improper construction.

Findings include:

1. On 5/12/14 while accompanied by Facility Representatives it was determined that in multiple Stair towers the distance between guardrails was observed to be in excess of 4" to comply with subpart (3) to 7.2.2.4.6 and 19.2.2.3. This condition was observed in multiple exit stairs. Example locations of Exit stair enclosures at which this condition was observed, include:

a. Exit Stair D
b. Exit Stair H

All exit stairs that do not comply with these requirements are considered deficient.

2. On 5/14/14 while accompanied by Facility Representatives it was determined by and observation that in the exit passageway adjacent to stair " B " contained double egress cross corridor doors that when tested did not latch to the frame. This door set forms a continuation of the exit stair and is required to have positive latching. This does not comply with NFPA 101, section 7.1.

3. On 5/14/14 while accompanied by Facility Representatives it was determined that in the exit passageway between exit stair towers " B " and " D " contained a staff time clock. Exit passageways cannot be used for an alternate purpose that has the potential to interfere with its use per NFPA 101, Section 7.1.3.2.3.

Based on observations and interviews, the facility failed to provide exit access that is readily accessible to a public-way at all times. This deficient practice could affect patients, staff and visitors by not allowing prompt egress in facilities not fully sprinkler protected.

Findings include:

1. On 5/12/14 while accompanied by Facility Representatives it was determined that in the " D " building 3rd floor contained several delayed egress doors located in egress corridors leading to an exit enclosure. Delayed egress doors are not permitted in non or partially sprinkled buildings. This does not comply with NFPA 101, 2000 Edition, Section 18.2.2.2.4 and 7.2.1.6.1.

2. On 5/12/14 while accompanied by Facility Representatives it was determined that in the " D " building 3rd floor contained 2 delayed egress doors in series leading to an exit enclosure. This does not comply with NFPA 101, 2000 Edition, Section 18.2.2.2.4 exception #2 and 7.2.1.6.1.

3. On 5/12/14 while accompanied by Facility Representatives it was determined that in the " D " building 3rd floor contained several delayed egress doors, When tested the delayed function automatically reset the door magnet. Manual door reset is required per NFPA 101, 2000 Edition, Section 7.2.1.6.1. (c).

4. On 5/12/14 while accompanied by Facility Representatives it was determined that in the " C " building 5th floor contained egress doors that were locked due to the clinical need of the area. This area is used for overflow from the physiological unit in the adjacent " D " building. At the time of the survey and observation and interview determined that this unit does not contain patients and therefore does not have the requirement for a clinical need and all exit doors must remain unlocked at all times. This deficiency does not comply with NFPA 101, Section 19.2.2.2.2. exception 2.

5. On 5/14/14 while accompanied by Facility Representatives it was determined that on the 1st floor exit discharge at 76th street contained an exterior concrete slab that had settled and created a threshold elevation change at the exterior of the door of +/- 3-inches. This does not comply with NFPA 101, Section 7.2.1.3.

6. On 5/14/14 while accompanied by Facility Representatives it was determined that on the 1st floor exit stair " G " did not contain a gate preventing occupants from proceeding to the basement during an emergency. Exit stairs extending beyond the level of exit discharge are required to contain a means for disrupting further access as per NFPA 101, Section 7.7.3.

Based on observations and interviews, the facility failed to provide exit path illumination. Illumination of means of egress, including the exit discharge is arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. This deficient practice could affect patients, staff and visitors, if the exit discharge is not properly illuminated during an evacuation at night.

Findings include:

1. On 5/14/14 while accompanied by Facility Representatives an observation and interview could not determined if the existing exit discharge lighting contained a 2 lamp fixture. There are several locations at the perimeter of the building that due to the height and configuration of the wall mounted fixture access to look inside the unit was limited. This does not comply with NFPA 101, Section 19.2.8 and 7.8.1.4.

Based on observations and interviews, it was determined that the facility failed to properly inspect all exit signs for proper operation. This deficient practice could affect patients, staff and visitors if exit sign are not functioning during an emergency.

Findings include:

1. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " E " Building on the 3rd floor, Day Room, contained (1) emergency exit sign that was not illuminated. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.5.2.

2. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " E " Building on the 4th floor, south, there is a missing exit sign at the double egress doors and a missing directional exit sign. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.1.1.

3. On 5/13/14 while accompanied by Facility Representatives an observation determined that in the " A " Building on the 2nd floor, north corridor adjacent to the medical office building bridge did not contain a directional exit sign. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.1.1.

4. On 5/13/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 1st floor stair vestibule at Stair " C " , contained (2) exit signs at double door sets that are not required. The stair vestibule forms a part of stair " C " and must discharge direct to the exterior of the building. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.1.1.

5. On 5/13/14 while accompanied by Facility Representatives an observation determined that in the " E " Building on the 1st floor, Dialysis Unit contained (1) exit sign that was not continually illuminated. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.5.2.

6. On 5/13/14 while accompanied by Facility Representatives an observation determined that in the " B " Building on the 1st floor, Room B111 contained (1) exit sign that was located over a locked door into an office. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.1.1.

7. On 5/14/14 while accompanied by Facility Representatives an observation determined that in the " D " Building, Basement, Kitchen, North exit door was installed with a slide blot latch and was not installed with an emergency exit sign over the door. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.1.1.

Based on observations and interviews, it was determined that the facility failed to properly secure and inspect all portable fire extinguishers. This deficient practice could affect patients, staff and visitors if extinguishers at not mounted and located properly.

Findings include:

1. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " E " Building on the 3rd floor, Day Room, contained 2 fire extinguishers that were sitting on the floor adjacent to the television stand. This does not comply with NFPA 101, 2000 Edition 19.3.5.6, 9.7.4.1 and NFPA 10.

Based on an observation, it was determined that a mechanical room was not being properly maintained. This deficient practice could affect patients, staff and visitors if smoke was to transfer into the egress path.

Findings include:

1. On 5/12/14 while accompanied by Facility Representatives it was determined that on the 5th floor, Mechanical room contained 6 beds with mattresses that were being stored in this space. This is not NFPA 101, Section 19.5.2.2.

Based on an observation and interview, the facility failed to ensure that the kitchen staff was properly trained on the use of the range hood (ANSUL) fire extinguishing system and portable fire extinguishers. This deficient practice could affect patients, staff and visitors in the kitchen and adjacent cafeteria if fire and smoke from a kitchen fire was not contained properly due to lack of training.

Findings include:

1. On 5/14/14 while accompanied by Facility Representatives it was determined by an Interview with Kitchen staff members that they have not been in-serviced regarding the proper sequence for activating the ANSUL hood extinguishing system and the use of the K-Type kitchen portable fire extinguisher if there was a fire at the cooking surface. Staff Training is not in accordance with NFPA 96, section 8-1.4.

2. On 5/12/14 while accompanied by Facility Representatives it was determined by and observation and an interview that on the 5th floor mechanical room contained a steel fully welded duct that was used for exhaust from the kitchen cooking area hood. It was observer that a +/- 14-foot section of horizontal duct was not installed with access. This does not comply with NFPA 96, Section 4-3.1.

3. On 5/12/14 while accompanied by Facility Representatives it was determined by and observation and an interview that on the 5th floor mechanical room contained a steel fully welded duct that was used for exhaust from the kitchen cooking area hood and exhaust from the dishwashing area. Commercial cooking exhaust hoods shall not be interconnected with any other building ventilation or exhaust system per NFPA 96, Section 4-1.3.

Based on observations, the facility failed to provide proper exhaust pressures in medical waste rooms. This deficient practice could affect patients, staff and visitors if proper ventilation of bio- hazardous air is not exhausted properly. Alternative life safety measures will be required throughout the monitoring of the facility corrections.

Findings Include:

1. On 5/14/14 while accompanied by Facility Representatives it was determined that in the " E " building 1st floor contained a medical waste room that was under positive air pressure. Bio-hazardous rooms are to be kept under negative pressure per clinical health tag A726.

2. 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 facility electrical supervisor, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the hospital if the emergency power system does not operate correctly.

Findings include:

1. On 5/13/14, the surveyor observed that the transfer switches in the main electrical rooms were serving distribution panels that served a mixture of life safety panels and critical panels throughout the buildings. This does not meet the requirements of NFPA-70, Section 517-30 through 517-35, for a system that serves over 150 KVA in loads.

2. On 5/12/14, the surveyor observed that the panel EMLP in the boiler room, panel FP1 and the emergency distribution panel in the Building-C fire alarm room were serving a mix of life safety, critical and equipment loads. These are examples of, but not of the panels that do not meet the requirements of NFPA-70, Section 517-32 through 517-34.

3. On 5/13/14, the surveyor observed that the Life safety panel EM-3, and critical panel CR-S3-1, (new panels in a remodeled area of building D), are served from a single transfer switch. NFPA-70, Section 517-30 requires that each branch of the emergency power system be served from its' own transfer switch for emergency power systems with maximum demand over 150 KVA.

Based on random observation during the survey walk through while accompanied by the facility electrical supervisor, 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. On 5/12/14, the surveyor observed that the elevator cab lights for elevator 9 & 10 were not equipped with a disconnect in the elevator equipment room in accordance with NFPA-70, Section 620-53.

2. On 5/12/14, the surveyor observed that the operating rooms, procedure rooms, recovery rooms, the ICU room headwalls, the ER rooms, and the trauma room were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-18, and 517-19.

3. On 5/12/14, the surveyor observed that the operating rooms and procedure rooms were not equipped with battery type emergency lighting to meet the requirements of NFPA-99, Section 3-3.2.1.2(a)5.e.

Based on an observation, it was determined that a section of the facility corridor wall failed to act as the smoke barrier, to meet the required 30-minute rating, for the exit egress path. This deficient practice could affect patients, staff and visitors if smoke was to transfer into the egress path.

Findings include:

1. On 5/14/14 while accompanied by Facility Representatives it was determined that in the basement, cafeteria, wall separating the kitchen from the cafeteria contained 3 sets of transfer grills that would not resist the passage of smoke. This does not comply with NFPA 101, Section 19.3.6.2.2 and 8.2.4.4.

Based on an observation it was determined that the facility failed to maintain the closure of the corridor doors per CMS. This deficient practice could affect patients, staff and visitors if a fire would start in this area. Corridor doors opening onto an exit corridor would not provide a proper smoke barrier during a fire emergency.

Findings include:

1. On 5/14/14 while accompanied by Facility Representatives it was determined that in the basement exit corridor leading to the cafeteria contained a set of double doors into a training room. The doors were not installed with positive latching hardware and the inactive door leaf was installed with manual flush bolts that would require constant monitoring to comply with the latching requirement. This does not comply with NFPA 101, Section 19.3.6.3.2 and SOM, Appendix I, Task 4.

2. On 5/13/14 while accompanied by Facility Representatives it was determined that on the 2nd floor, LDR suite contained a set of double doors on the east side of the suite. An observation determined that the north door leaf did not latch to the frame during fire alarm testing. This does not comply with NFPA 101, Section 19.3.6.3.2.

Based on observations of a hazardous area and interviews, the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

1. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 9th floor, room 923 is being used as a storage room and the door is not equipped with a door closer. All doors and frames protecting storage rooms located in non-sprinkler protected areas/zones are to be rated for a minimum of 1-hour. This is not per NFPA 101, section 19.3.2.1.

2. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 9th floor, room 923B is being used as a storage room and the door is not equipped with a door closer. All doors and frames protecting storage rooms located in non-sprinkler protected areas/zones are to be rated for a minimum of 1-hour. This is not per NFPA 101, section 19.3.2.1.

3. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 9th floor, room 929 is being used as a storage room and the door closer installed was not properly connected and did not close the door to the frame when tested. All doors and frames protecting storage rooms located in non-sprinkler protected areas/zones are to be rated for a minimum of 1-hour. This is not per NFPA 101, section 19.3.2.1.

4. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 9th floor, room 931 is being used as a storage room and the door closer installed was not properly connected and did not close the door to the frame when tested. All doors and frames protecting storage rooms located in non-sprinkler protected areas/zones are to be rated for a minimum of 1-hour. This is not per NFPA 101, section 19.3.2.1.

5. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 8th floor, room 823 is being used as a storage room and the door is not equipped with a door closer. All doors and frames protecting storage rooms located in non-sprinkler protected areas/zones are to be rated for a minimum of 1-hour. This is not per NFPA 101, section 19.3.2.1.

6. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 6th floor, Storage Room doors are not equipped with door closers. All doors and frames protecting storage rooms located in non-sprinkler protected areas/zones are to be rated for a minimum of 1-hour. This is not per NFPA 101, section 19.3.2.1.

7. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " E " Building on the 4th floor, Clean Utility Room door to the corridor did not latch to the door frame when tested. This is not per NFPA 101, section 19.3.2.1.

8. On 5/13/14 while accompanied by Facility Representatives an observation determined that in the " B " Building on the 1st floor, Storage Room adjacent to Stair to basement and B111 was not installed with a door closer. This is not per NFPA 101, section 19.3.2.1.

9. On 5/14/14 while accompanied by Facility Representatives an observation determined that in the " D " Building, Basement, Kitchen contained 2 doors that opened into the cafeteria and exit path that were not installed with proper latching door hardware. This is not per NFPA 101, section 19.3.2.1.

Based on observations it was determined that the facility did not provide exits with properly configured stair components or prohibited the use of these space from alternate activities. This deficient practice could affect patients, staff and visitors, by preventing those occupants from reaching an exit discharge from the building due to improper construction.

Findings include:

1. On 5/12/14 while accompanied by Facility Representatives it was determined that in multiple Stair towers the distance between guardrails was observed to be in excess of 4" to comply with subpart (3) to 7.2.2.4.6 and 19.2.2.3. This condition was observed in multiple exit stairs. Example locations of Exit stair enclosures at which this condition was observed, include:

a. Exit Stair D
b. Exit Stair H

All exit stairs that do not comply with these requirements are considered deficient.

2. On 5/14/14 while accompanied by Facility Representatives it was determined by and observation that in the exit passageway adjacent to stair " B " contained double egress cross corridor doors that when tested did not latch to the frame. This door set forms a continuation of the exit stair and is required to have positive latching. This does not comply with NFPA 101, section 7.1.

3. On 5/14/14 while accompanied by Facility Representatives it was determined that in the exit passageway between exit stair towers " B " and " D " contained a staff time clock. Exit passageways cannot be used for an alternate purpose that has the potential to interfere with its use per NFPA 101, Section 7.1.3.2.3.

Based on observations and interviews, the facility failed to provide exit access that is readily accessible to a public-way at all times. This deficient practice could affect patients, staff and visitors by not allowing prompt egress in facilities not fully sprinkler protected.

Findings include:

1. On 5/12/14 while accompanied by Facility Representatives it was determined that in the " D " building 3rd floor contained several delayed egress doors located in egress corridors leading to an exit enclosure. Delayed egress doors are not permitted in non or partially sprinkled buildings. This does not comply with NFPA 101, 2000 Edition, Section 18.2.2.2.4 and 7.2.1.6.1.

2. On 5/12/14 while accompanied by Facility Representatives it was determined that in the " D " building 3rd floor contained 2 delayed egress doors in series leading to an exit enclosure. This does not comply with NFPA 101, 2000 Edition, Section 18.2.2.2.4 exception #2 and 7.2.1.6.1.

3. On 5/12/14 while accompanied by Facility Representatives it was determined that in the " D " building 3rd floor contained several delayed egress doors, When tested the delayed function automatically reset the door magnet. Manual door reset is required per NFPA 101, 2000 Edition, Section 7.2.1.6.1. (c).

4. On 5/12/14 while accompanied by Facility Representatives it was determined that in the " C " building 5th floor contained egress doors that were locked due to the clinical need of the area. This area is used for overflow from the physiological unit in the adjacent " D " building. At the time of the survey and observation and interview determined that this unit does not contain patients and therefore does not have the requirement for a clinical need and all exit doors must remain unlocked at all times. This deficiency does not comply with NFPA 101, Section 19.2.2.2.2. exception 2.

5. On 5/14/14 while accompanied by Facility Representatives it was determined that on the 1st floor exit discharge at 76th street contained an exterior concrete slab that had settled and created a threshold elevation change at the exterior of the door of +/- 3-inches. This does not comply with NFPA 101, Section 7.2.1.3.

6. On 5/14/14 while accompanied by Facility Representatives it was determined that on the 1st floor exit stair " G " did not contain a gate preventing occupants from proceeding to the basement during an emergency. Exit stairs extending beyond the level of exit discharge are required to contain a means for disrupting further access as per NFPA 101, Section 7.7.3.

Based on observations and interviews, the facility failed to provide exit path illumination. Illumination of means of egress, including the exit discharge is arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. This deficient practice could affect patients, staff and visitors, if the exit discharge is not properly illuminated during an evacuation at night.

Findings include:

1. On 5/14/14 while accompanied by Facility Representatives an observation and interview could not determined if the existing exit discharge lighting contained a 2 lamp fixture. There are several locations at the perimeter of the building that due to the height and configuration of the wall mounted fixture access to look inside the unit was limited. This does not comply with NFPA 101, Section 19.2.8 and 7.8.1.4.

Based on observations and interviews, it was determined that the facility failed to properly inspect all exit signs for proper operation. This deficient practice could affect patients, staff and visitors if exit sign are not functioning during an emergency.

Findings include:

1. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " E " Building on the 3rd floor, Day Room, contained (1) emergency exit sign that was not illuminated. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.5.2.

2. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " E " Building on the 4th floor, south, there is a missing exit sign at the double egress doors and a missing directional exit sign. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.1.1.

3. On 5/13/14 while accompanied by Facility Representatives an observation determined that in the " A " Building on the 2nd floor, north corridor adjacent to the medical office building bridge did not contain a directional exit sign. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.1.1.

4. On 5/13/14 while accompanied by Facility Representatives an observation determined that in the " C " Building on the 1st floor stair vestibule at Stair " C " , contained (2) exit signs at double door sets that are not required. The stair vestibule forms a part of stair " C " and must discharge direct to the exterior of the building. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.1.1.

5. On 5/13/14 while accompanied by Facility Representatives an observation determined that in the " E " Building on the 1st floor, Dialysis Unit contained (1) exit sign that was not continually illuminated. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.5.2.

6. On 5/13/14 while accompanied by Facility Representatives an observation determined that in the " B " Building on the 1st floor, Room B111 contained (1) exit sign that was located over a locked door into an office. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.1.1.

7. On 5/14/14 while accompanied by Facility Representatives an observation determined that in the " D " Building, Basement, Kitchen, North exit door was installed with a slide blot latch and was not installed with an emergency exit sign over the door. This does not comply with NFPA 101, 2000 Edition 19.2.10.1 and 7.10.1.1.

Based on observations and interviews, it was determined that the facility failed to properly secure and inspect all portable fire extinguishers. This deficient practice could affect patients, staff and visitors if extinguishers at not mounted and located properly.

Findings include:

1. On 5/12/14 while accompanied by Facility Representatives an observation determined that in the " E " Building on the 3rd floor, Day Room, contained 2 fire extinguishers that were sitting on the floor adjacent to the television stand. This does not comply with NFPA 101, 2000 Edition 19.3.5.6, 9.7.4.1 and NFPA 10.

Based on an observation, it was determined that a mechanical room was not being properly maintained. This deficient practice could affect patients, staff and visitors if smoke was to transfer into the egress path.

Findings include:

1. On 5/12/14 while accompanied by Facility Representatives it was determined that on the 5th floor, Mechanical room contained 6 beds with mattresses that were being stored in this space. This is not NFPA 101, Section 19.5.2.2.

Based on an observation and interview, the facility failed to ensure that the kitchen staff was properly trained on the use of the range hood (ANSUL) fire extinguishing system and portable fire extinguishers. This deficient practice could affect patients, staff and visitors in the kitchen and adjacent cafeteria if fire and smoke from a kitchen fire was not contained properly due to lack of training.

Findings include:

1. On 5/14/14 while accompanied by Facility Representatives it was determined by an Interview with Kitchen staff members that they have not been in-serviced regarding the proper sequence for activating the ANSUL hood extinguishing system and the use of the K-Type kitchen portable fire extinguisher if there was a fire at the cooking surface. Staff Training is not in accordance with NFPA 96, section 8-1.4.

2. On 5/12/14 while accompanied by Facility Representatives it was determined by and observation and an interview that on the 5th floor mechanical room contained a steel fully welded duct that was used for exhaust from the kitchen cooking area hood. It was observer that a +/- 14-foot section of horizontal duct was not installed with access. This does not comply with NFPA 96, Section 4-3.1.

3. On 5/12/14 while accompanied by Facility Representatives it was determined by and observation and an interview that on the 5th floor mechanical room contained a steel fully welded duct that was used for exhaust from the kitchen cooking area hood and exhaust from the dishwashing area. Commercial cooking exhaust hoods shall not be interconnected with any other building ventilation or exhaust system per NFPA 96, Section 4-1.3.

Based on observations, the facility failed to provide proper exhaust pressures in medical waste rooms. This deficient practice could affect patients, staff and visitors if proper ventilation of bio- hazardous air is not exhausted properly. Alternative life safety measures will be required throughout the monitoring of the facility corrections.

Findings Include:

1. On 5/14/14 while accompanied by Facility Representatives it was determined that in the " E " building 1st floor contained a medical waste room that was under positive air pressure. Bio-hazardous rooms are to be kept under negative pressure per clinical health tag A726.

2. 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 facility electrical supervisor, the surveyor found that the electrical system installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the hospital if the emergency power system does not operate correctly.

Findings include:

1. On 5/13/14, the surveyor observed that the transfer switches in the main electrical rooms were serving distribution panels that served a mixture of life safety panels and critical panels throughout the buildings. This does not meet the requirements of NFPA-70, Section 517-30 through 517-35, for a system that serves over 150 KVA in loads.

2. On 5/12/14, the surveyor observed that the panel EMLP in the boiler room, panel FP1 and the emergency distribution panel in the Building-C fire alarm room were serving a mix of life safety, critical and equipment loads. These are examples of, but not of the panels that do not meet the requirements of NFPA-70, Section 517-32 through 517-34.

3. On 5/13/14, the surveyor observed that the Life safety panel EM-3, and critical panel CR-S3-1, (new panels in a remodeled area of building D), are served from a single transfer switch. NFPA-70, Section 517-30 requires that each branch of the emergency power system be served from its' own transfer switch for emergency power systems with maximum demand over 150 KVA.

Based on random observation during the survey walk through while accompanied by the facility electrical supervisor, 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. On 5/12/14, the surveyor observed that the elevator cab lights for elevator 9 & 10 were not equipped with a disconnect in the elevator equipment room in accordance with NFPA-70, Section 620-53.

2. On 5/12/14, the surveyor observed that the operating rooms, procedure rooms, recovery rooms, the ICU room headwalls, the ER rooms, and the trauma room were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-18, and 517-19.

3. On 5/12/14, the surveyor observed that the operating rooms and procedure rooms were not equipped with battery type emergency lighting to meet the requirements of NFPA-99, Section 3-3.2.1.2(a)5.e.