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A. Based on observation durng the afternoon fire alarm testing, the surveyor found the Hospital building was not separated from the Business Occupancy building by a fire barrier with two hour fire resistance rating in accordance with 19.1.1.4.1. Findings include:

1. One door in the pair of doors in the communicating opening in the fire barrier between the nonconforming 1960 Business Occupancy building and the 2002 Hospital Addition did not close on activation of the fire alarm as required by 19.1.1.4.2.

A. Based on observation during the walk-through, corridor doors are not positive latching in accordance with 19.3.6.3. Findings include:

1. At 2:35 pm , the surveyors observed that the corridor door to Room 525 Staff Lounge does not have positive latching hardware to comply with 19.3.6.3.2.

A. Based on observation during the walk-through, hazardous areas are not protected in accordance with 19.3.2.1. Findings include:

1 The OR Storage room door was observed to not be self-closing to a latched condition to comply with 19.3.2.1.

A. Based on random observation during the survey walk-through and staff interview, emergency illumination is not provided in accordance with NFPA 101-2000, 19.2.9.1, 7.9 and NFPA 99-1999, 3-3.2.1.2.

Findings include:

1. The Operating rooms were observed on the afternoon of 3/20/13 to not be provided with battery powered emergency lighting to comply with NFPA 99-1999, 3-3.2.1.2(a)5.e.

Based on observation during survey walk-through, surveyor noted that the emergency generator was not in accordance with NFPA 99, 1999 Edition, Sections 3-4.2.2.2. and 3-4.2.1.4, and by NFPA 110, 1999 Edition. Findings include:

1. The generator was observed, at 2:50 pm to lack an automatically controlled heater as required by NFPA 110, Section 3-3.1, 1999 Edition.

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.

A. Based on observation during survey walk-through, surveyors noted that the Critical Branch [NFPA 99, 1999 Edition, Section 3-4-2-2-2(b)] includes items required to be on the Life Safetey Branch. Findings include:

1. At 2: 15 pm, surveyor observed the fire alarm circuit was found on the Electrical Panel labeled EC1A in the Emerency Department. By interview with the Director of Environmental Services, the electrical panels labeled EC are the circuits of the critical branch.

A. Based on observation durng the afternoon fire alarm testing, the surveyor found the Hospital building was not separated from the Business Occupancy building by a fire barrier with two hour fire resistance rating in accordance with 19.1.1.4.1. Findings include:

1. One door in the pair of doors in the communicating opening in the fire barrier between the nonconforming 1960 Business Occupancy building and the 2002 Hospital Addition did not close on activation of the fire alarm as required by 19.1.1.4.2.

A. Based on observation during the walk-through, corridor doors are not positive latching in accordance with 19.3.6.3. Findings include:

1. At 2:35 pm , the surveyors observed that the corridor door to Room 525 Staff Lounge does not have positive latching hardware to comply with 19.3.6.3.2.

A. Based on observation during the walk-through, hazardous areas are not protected in accordance with 19.3.2.1. Findings include:

1 The OR Storage room door was observed to not be self-closing to a latched condition to comply with 19.3.2.1.

A. Based on random observation during the survey walk-through and staff interview, emergency illumination is not provided in accordance with NFPA 101-2000, 19.2.9.1, 7.9 and NFPA 99-1999, 3-3.2.1.2.

Findings include:

1. The Operating rooms were observed on the afternoon of 3/20/13 to not be provided with battery powered emergency lighting to comply with NFPA 99-1999, 3-3.2.1.2(a)5.e.

Based on observation during survey walk-through, surveyor noted that the emergency generator was not in accordance with NFPA 99, 1999 Edition, Sections 3-4.2.2.2. and 3-4.2.1.4, and by NFPA 110, 1999 Edition. Findings include:

1. The generator was observed, at 2:50 pm to lack an automatically controlled heater as required by NFPA 110, Section 3-3.1, 1999 Edition.

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.

A. Based on observation during survey walk-through, surveyors noted that the Critical Branch [NFPA 99, 1999 Edition, Section 3-4-2-2-2(b)] includes items required to be on the Life Safetey Branch. Findings include:

1. At 2: 15 pm, surveyor observed the fire alarm circuit was found on the Electrical Panel labeled EC1A in the Emerency Department. By interview with the Director of Environmental Services, the electrical panels labeled EC are the circuits of the critical branch.