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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. Corrected 1/15/15

3. Corrected 1/15/15

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. Corrected by Categorical Waiver 1/15/15
2. Corrected 1/15/15
3. Corrected 1/15/15

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. Corrected 1/15/15
6. Corrected 1/15/15

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. Corrected 1/15/15

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.