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A. Based upon random observation during the survey walk through, accompanied by two contractor foremen, the surveyor finds that a non-conforming building is not separated from the health care occupancy by two hour rated construction as required by 19.1.1.4.1. This deficiency could affect the patients, staff, and visitors within the Hamilton Building in the event of a fire in the non-conforming building.

Findings include:

1. At 12:50 PM on April 9, 2014, on the Hamilton 3rd floor, a combustible trailer was observed to have been added to the facility adjacent to the tunnel at the west side of the building near the Imaging Department. The trailer was not separated from the tunnel by doors having a rating of 1 ½ hour. 8.2.3.2.3.1

Based on document review and based on random observation with the Director of Facilities and the Safety Officer present, the surveyor observed that portions of the East/West Building do not comply with 19.1.6.2.

Findings include:

1. The 6th Floor Admitting Office at the west end of the East/West Building was found to have a suspended lay-in ceiling below a plaster ceiling. The plaster ceiling is attached directly to the reinforced concrete structure above. A portion of the plaster ceiling was removed and a 4' strip running parallel to the two hour fire separation between East/West and Hamilton was fire-proofed for the entire width of the room. The provider had no explanation as to why this area was fire-proofed. The provider also lacks U L Design Numbers for the floor/ceiling assemblies used in the East/West Building where the plaster ceilings have been removed.

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke to enter the egress corridor.

Findings include:

A. At 2:13 PM on April 9, 2014, while accompanied by the provider's Electrician and HVAC Specialist: The Third Floor Endoscopy Reception Area, which is not constantly attended and which was observed to be open to the adjacent corridor, was observed to lack a smoke detector required by Subpart (c) of Exception 1. to 19.3.6.1.


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B. At 3:12 PM on April 9, 2014, on the Southwest Building 1st floor accompanied by two contractor foremen, a cashier ' s office at the main entry corridor which is not constantly attended and which was observed to be open to the adjacent corridor, was observed to lack a smoke detector required by Subpart (c) of Exception 1 to 19.3.6.1.

A. Based on observation on 04/09/14, with the Director of Facilities and the Safety Officer present, the surveyor found the the 6th Floor of the East/West Building is an inpatient psychiatric unit with patient sleeping rooms. The north extension of the East/West Building is identified with exit signs as a required means of egress. The north end of this required exit access corridor through the Information Technologies Area (IT) does not comply with 19.3.6.3.2. Devices which prevent a door from closing an latching in one single motion could result in migration of fire and smoke beyond the room of fire origin.

Findings include:

1 The 90 minute fire door to the RICOH Room was wedged open.

2. The corridor door to the IT Room was wedged open.

A Based on document review of plans dated 3/31/14, and based on observation with the Director of Facilities and the Safety Officer present, the surveyor finds that vertical openings do not comply with 19.3.1.1

Findings include:

1. The 4th Floor Physical Therapy Unit: Door 30483 to the PTS Break Room: A shaft access panel was found open; the shaft access panel was not fire rated, self closing and positive latching. (NFPA 80)

2. The 4th Floor Physical Therapy Unit: The vertical shaft next to the South Exit Stair from this unit has a shaft access panel which was not fire rated, self closing and positive latching. (NFPA 80)

Lack of proper enclosure of vertical shafts could result in movement of fire and smoke to multiple floors in a fire emergency

A. Based on document review of plans dated 3/31/14 and based on observation with the Director of Facilities and the Safety Officer present on 04/11/14, the surveyor finds that the 3rd Floor Kitchen does not comply with 7.2.1.8 of NFPA 101.

Findings include:

1. A 3rd Floor Kitchen Storage Room has a pair of 90 minute fire doors on magnetic hold open devices. Smoke detectors on both sides of the doors were not found to automatically release and close the doors in accordance with NFPA 72.

Failure to maintain fire doors will allow fire and smoke to spread beyond the room of fire origin.

A. Based on document review of plans dated 3/31/14 and based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that designated smoke compartments do not comply with 19.3.7.1. Failure to identify and maintain required smoke barriers could allow smoke to spread beyond the compartment of fire origin.

Findings include:

1. The plans dated 03/31/14 identify the entire East/West building as one single smoke compartment on the 5th, 6th, 7th and 8th Floors. Although one hour fire barriers further subdivide each floor, these one hour fire barriers are not identified as smoke barriers. A two hour barrier identified on the north end of the East Building is also not identified as a two hour fire/smoke barrier.

The travel distance on Floors 5, 6 and 7 from the north end of the East Building, as indicated on the smoke compartment plans, exceeds the 200' travel distance limitations of 19.3.7.1 to the closest identified smoke barrier doors. See also K038.

A. Based on document review of plans dated 3/31/14 and based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that exit access corridors are used improperly and hazardous areas are not enclosed and protected in accordance with 19.3.2.1. Failure to install and maintain enclosure of hazardous areas could result in an uncontrolled fire spreading beyond the room of fire origin.

Findings include:

1. 5 West: The storage room between the conference room and the restroom lacks a self closing door in accordance with 19.3.2.1 and 39.3.2.

2. 4th Floor North Corridor for the East/West Building: A niche in the east side of the corridor, just south of a Soiled Holding Room, is used to hold soiled linen carts and soiled linen. This use in a corridor does not comply with 19.3.2.1 and 19.3.6.1.

3. 4th Floor North Corridor for the East/West Building: The 90 minute fire door to the Soiled Linen Room hangs up on the floor and is not self closing in accordance with NFPA 80 and 7.2.1.8 of NFPA 101.

B. Based on observation on 04/09/14, with the Director of Facilities and the Safety Officer present, the surveyor found the the 6th Floor of the East/West Building is an inpatient psychiatric unit with patient sleeping rooms. The north extension of the East Building is identified with exit signs as a required means of egress.

There is a one hour fire barrier in this north corridor which separate the patient area from Information Technology Area (IT). The exit access corridor leading to the north exit stair
inside this IT area is a required exit path for the Psych Unit and it was obstructed by storage which did not comply with 19.3.2.1 and/or 3.6.1.

Failure to maintain means of egress free of combustibles could quickly compromise patient movement and evacuation in a fire emergency.

Based on random observation during the survey walk-through, accompanied by two contractor foremen, the surveyor finds that exit access is not arranged so that exits are readily accessible at all times in accordance with 38.2.1. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the building.

Findings include:

A. At 1:00 PM on April 10, 2014, on the 1st floor of the Hamilton Entry Building, the main atrium space and waiting areas were observed to have a single exit and a common path of travel distance of 112 feet, whitch exceeds that which is permitted by 38.2.5.3 Exception 1 and an exit path to the east was not identified at the horizontal exit identified on the life safety drawings, dated 3-31-14, as required by 38.2.10.

Based on random observation during the survey walk-through, not all exit stair shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1. This deficiency could affect any patients, staff, or visitors utilizing the Exit Stair by permitting smoke or fire to enter the Exit Stair enclosure.

Findings include:

1. At 9:37 AM on April 10, 2014, while accompanied by the provider's Electrician and HVAC Technician: The penetrations by support channels into the fire rated drywall enclosure partition, at the South Exit Stair landing between the Sixth and Fifth Floors, were observed to not be sealed against the passage of fire as required by 8.2.3.2.4.2.

A Based on observation on 04/11/14, with the Director of Facilities and the Safety Officer present the surveyor finds that the North Glen Oak Stair has multiple deficiencies at the 1st Floor and does not comply with 7.1.3.2, 9.2.1 and 19.3.3.2 of NFPA 101

Findings include:

1 The 1st Floor North Exit Stair wall finishes are identified as FRP (fiber reinforced plastic). The Provider lacks documentation for this material which identifies it as a Class A or Class B Interior Finish in accordance with 19.3.3.2.

2. There is a duct penetration with a fire damper above one of the 1st Floor doors into the stair.

a. The fire damper lacks retaining angle on
the none stair side of the fire barrier in
accordance with NFPA 90.

b. There is a void in the wall next to the
above referenced fire damper. The wall at
this void is only 4" of glazed tile or
pyrobar and is not two hour fire rated
construction.

A. Based on document review of plans dated 3/31/14 and based on observation with the Director of Facilities and the Safety Officer present on 04/11/14, the surveyor finds that the 4th Floor Cafeteria has a designated exit path through a North Exit Stair to the outside. This exit path does not comply with 7.2.2.4.2 of NFPA 101

Findings include:

1. The exterior exit discharge at the outside requires travel up three or four steps to reach grade. These steps lack handrails on both sides of the steps.

Lack of railings could cause injury to anyone using the steps in an emergency.

Based on random observation during the survey walk-through, accompanied by two contractor foremen, the surveyor finds that not all exit access doors from patient rooms are equipped with hardware which will permit egress from the room. This deficiency could affect the ability of patients or staff locked in the room from reaching an exit in the event of an emergency.

Findings include:

1. At 11:00 AM on April 10, 2014 on the Hamilton 8th floor it was observed that corridor doors to patient bedrooms in the psychiatric unit are equipped with deadbolts that do not have thumb turns or other means to unlock the door from the interior. The provider lacks a written policy which includes when and how these doors may be locked and what procedures are required to confirm that the space is empty of patients before the door is locked. 19.2.2.2.2

A. Based on document review of plans dated 3/31/14 and based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that designated two hour fire barriers do not comply with 8.2.3 of NFPA 101 and NFPA 80. Failure to maintain designated fire barriers will allow fire and smoke to spread into adjacent fire compartments and/or buildings during a fire emergency.

Findings include:

1. The 6th Floor single door between the East/West Building and Hamilton is identified as a two hour fire barrier. The door lacks a U L Label as a 90 minute fire door. The glazing in the door lacks identification as glazing which is rated for 90 minutes and also lacks identification as safety glazing.

2. 4th Floor North Corridor for the East/West Building: The "House" office has a 90 minute fire door, in a two hour wall, which opens into the Kitchen to the west. The door does not self close to a latched condition.

A Based on document review of testing with the electrical personnel responsible for testing and with the Director of Facilities and the Safety Officer present the surveyor finds that some emergency lights with battery back-up are not tested in accordance with 7.9.3 .of NFPA 101. Failure to test and maintain emergency lighting could result in total darkness during a power failure and/or temporary darkness at a critical point.


Findings include:

1. The documentation of 90 minute annual testing was reviewed for multiple devices. Although the written procedure on the providers documents call of a 90 minute test, a few of the devices were only tested for 60 minutes and/or some period less than 90 minutes. Example: Device 28668 was last tested annually only for 60 minutes. The surveyor notes that the testing documentation is not specific to building or location. This citation applies to all buildings with emergency lighting and or exit signs which have battery back up.

Based on random observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases in accordance with 19.2.10.1. and 7.10. This deficiency could affect any patients, staff, or visitors in the cited area by preventing them from safely exiting the building under fire conditions.

Findings include:

A. At 2:29 PM on April 9, 2014, while accompanied by the provider's Electrician and HVAC Specialist: The egress path from the Third Floor Admitting Unit, which includes multiple doors in close proximity to each other, was observed to not be identified by an exit sign as required by 7.10.1.1.


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B. At 3:00 PM on April 9, 2014, on the Southwest Building 1st floor it was observed that a second means of egress to the east is not identified with an illuminated exit sign when viewed from the corridor at the doors into the Hamilton Entry Building. 19.2.5.9, 19.2.10.1

A. Based on a review of plans which were provided for this survey (Plans dated 3/31/14) the surveyor observes that the East/West Building is identified by the provider as Type II (222) construction, as defined by NFPA 220. The East/West Building is immediately adjacent to the Loading Dock and Service Building at the east side of the East/West Building, Portions of the Service Building at Type II (000). The East/West building does not comply with 19.1.6.2 unless it is separated from the Service Building.

Findings include

1. The plans do not identify a two hour fire barrier between the East/West Building and the Service Building at the 5th Floor required by19.1.2.3 and 19.1.6.2.

B. The plan dated 3/31/14, show a corridor tunnel connecting the East/West Building on the 3rd Floor to the Crescent Building. The plans identify a horizontal exit at each end of the tunnel but the symbols used do not clearly indicate that an exit path is provided only to leave the tunnel and not enter it.

Based on document review, fire drills do not include the transmission of a signal in accordance with 19.7.1.2. This deficiency could affect any patients, staff, or visitors in the building because the fire alarm system may not function properly under a fire emergency.

Findings include:

A. During document review conducted at 8:15 AM on April 11, 2014, while accompanied by the provider's Safety Officer: It was determined that fire drills (at least once per quarter per shift) do not always include the transmission of a fire alarm signal as required by 19.7.1.2. According to the provider's records, fire drills during the quarters and shifts listed below did not include the transmission of a signal:
1. First Quarter, First Shift, 2013.

2. First Quarter, Second Shift, 2013.

3. Second Quarter, First Shift, 2013.

4. Second Quarter, Third Shift, 2013.

5. Fourth Quarter, Second Shift, 2013.

6. First Quarter, Second Shift, 2014.

7. First Quarter, Third Shift, 2014.

A Based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that fire alarm pull stations are not installed in accordance with NFPA 72. Failure to install fire alarm components in accordance with the codes could delay activation of the fire alarm system in a fire emergency.

Findings include:

1. The north extension of the 5th Floor Corridor on 5 East extends to a North Exit Stair. A fire alarm pull station was found in front of an abandoned elevator opening, well away from the North Stair. A fire alarm pull station was not installed within five feet of the exit in accordance with NFPA 72 1999 2-8.2.2.

2. The East Exit Stair on the 4th Floor of the East/West Building lacks a fire alarm pull station within five feet of the exit. (NFPA 72 1999 2-8.2.2)

3. Because a pattern was observed, of not having pull stations within five feet of each exit, was observed on multiple locations in the East/West Building and also in the Glen Oak Building, the surveyor expects to find similar conditions on all floors of these buildings.

Based on document review, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. These deficiencies could affect any staff or visitors in the building because the fire alarm and related systems could fail to operate under emergency conditions.

Findings include:

A. During an interview held in the Facilities Conference Room at 8:10 AM on April 11, 2014, the provider's Safety Officer stated that the Atrium smoke evacuation/control system is not tested semi-annually as required by NFPA 72 1999 Table 7-3.1.

B. During the document review process conducted at 8:45 AM on April 11, 2014, while accompanied by the provider's Safety Officer: It was determined that fire alarm system components failed to operate properly during tests of the system and there are no records available which show that corrective actions were taken as required by NFPA 72 1999 7-1.1.2. In a report from the fire alarm test dated June 13, 2013, a number of devices are listed as being "off" or as providing "no answer."

A. The provider identified the Glen Oak Building as fully sprinklered. Based on observation with the Director of Facilities and the Safety Officer present,the surveyor finds that the sprinkler system is not installed and maintained in accordance with NFPA 13 - 1999.

Findings include:

1. The 9th Floor Glen Oak Penthouse has a space in the corner which has 480 volt equipment. It is partially enclosed in masonry but has a large sheet of plywood over an opening. This space does not comply with NFPA 13 exceptions for unsprinklered spaces due to the lack of a two hour fire rated enclosure.

2. 5th Floor Room door 30128: the room has two closets. One closet lacks sprinkler protection and the sprinkler head in the second closet is obstructed by a beam.

3. Arm-over bracing for sprinkler heads are not installed at arm overs greater than 24" and at end of a branch lines where distance to hangers exceed 24" in length in accordance with NFPA 13 1999 6-2.3.4. Locations observed included multiple floors above ceilings of the Glen Oak Building

A. Based on document review of annual fire pump testing with the Director of Facilities and the Safety Officer present, the surveyor finds that the fire pump is not tested on emergency power in accordance with NFPA 25, and documented.

1. The documentation for annual fire pump testing for the previous three years fails to identify any testing on emergency power and the testing steps identified under 5-3.3.4 of NFPA 25- 1998.

The fire pump is connected to all but one building of this facility. Failure to test and maintain the fire pump could result in a failure of the sprinkler system in all of the buildings connected to the fire pump during a power failure.


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Based on observation during the survey walk-through, the surveyor finds that the facility failed to maintain automatic sprinkler protection in accordance with the requirements of NFPA 101-2000, 19.3.5, NFPA 13-1999, Chapter 5 and NFPA 25-1998, 2-2.1.1. Failure to install and maintain sprinkler protection could result in partial coverage and spread of fire and smoke in a fire emergency.

Locations include but are not necessarily limited to:

B. During the survey walk through with the Construction Manager and HVAC Staff, it was observed that multiple sprinkler heads in this building were covered with a heavy accumulation of lint and dust and/or the sprinkler heads were otherwise impaired. Locations observed include:

1. 8th Floor Crescent Pavilion, Simulation Learning Center (Old Patients' Room).

2. 7th Floor Crescent Pavilion, Soiled Utility Room for the Respiratory / Medical Unit.

3. 6th Floor Crescent Building, Storage Room across the Soiled Utility Room and the Nourishment Center.

4. 5th Floor Crescent Building, Cath Lab and Open Heart Institute, Women's Locker Room.

5. 4th Floor Crescent Building, Microbiology Area, Cytology Room.

C. Sprinkler head escutcheons were observed to be missing and do not comply with NFPA 25 1998 2-4.1.8. Locations include but are not limited to:

1. 7th Floor Crescent Building, ICU - Alcove near the Soiled Utility Room.

2. 4th Floor Crescent Building, Laboratory by the Specimen Receiving Area, in the LIS Program Manager Room and the sprinkler head located inside the lab's refrigerator is bent.

4. 4th Floor Crescent Building, Information System Room.

D. Sprinkler heads were observed which are being obstructed and do not comply with NFPA 13 1999 5-7.6.

1. 6th Floor Crescent Building - Supply materials located in two Closets of the Nursing Office are being stored less than 18 inches below the sprinkler heads and obstruct the deflector of the sprinklers which do not comply with NFPA 13 1999 5-6.6.

D. The above conditions are not being identified and abated based on an annual sprinkler inspection in accordance with NFPA 25.

A. Based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that HVAC systems are not installed and maintained in accordance with 4.5.7and 8.2.3.2.3 of NFPA 101 and with NFPA 90A.

Findings include

1. A vertical duct for an exhaust system serving floors 4 - 8 with an exhaust fan on the roof above the 8th Floor had a fire damper in the floor of the 7 West Mechanical Space. The fire damper was closed and the exhaust system was not functioning for the spaces below

2. A louver in the corridor wall on 7 West near a nurse managers office was mostly blocked by dust and lint.

3. A 6th Floor mechanical space opposite Room 631 had a combination fire/smoke damper installed in the floor above and below which were not installed in the plane of the fire barrier in accordance with the fire damper manufacturer's requirements and 2-3.8 of NFPA 90A - 1999.

4. A 6th Floor mechanical space opposite Room 631 has multiple duct which penetrate the corridor wall. This mechanical space and similar spaces above and below on other floors appear to be required two hour enclosures because of the vertical exhaust duct running through them (see Item 1 above}. The provider was not able to demonstrate compliance with NFPA 90A - 1999:

a. The provider indicated that these
duct penetrations through the
corridor walls have fire dampers;
however the provider was not able
to provide access for inspection
bcause the damper access panels
in the ceiling were locked.

b. The plans provided do not identify
these mechanical spaces and the
plans do not identify two hour shaft
walls around these mechanical
spaces.

5. A mechanical space next to Room 609 has an air handling unit with supply ducts penetrating the corridor wall. The space also has a vertical exhaust duct which runs from the 4th Floor to a fan on the roof. This duct penetrates the same mechanical space on floors 5 - 8 and has fire dampers installed where the duct penetrates each floor. This damper arrangement does not comply with NFPA 90A, section 3-3.4.1. However, each mechanical room on the floors above are to be designed to serve as a two hour shaft enclosure and fire dampers would only be required where the exhaust duct penetrates the 5th Floor slab instaed of at every slab The provider indicates that fire dampers are installed in the corridor walls as part of this shaft enclosure.

a. Four ducts penetrate the corridor
wall above the ceiling. The provider
indicated that these duct
penetrations through the corridor
walls have fire dampers; however
the provider was not able to provide
access for inspection because the
damper access panels in the ceiling
were locked.

b. The plans provided do not identify
these mechanical spaces and the
plans do not identify two hour shaft
walls around these mechanical
spaces.

6. The 5th Floor Mechanical Space, at the same location as Item 1 above, in the West Building was recently combined with a RO Water Room (dialysis). The mechanical room is not identified on plans and the plans identify a one hour corridor wall instead of a two hour fire rated shaft/corridor wall. Two corridor doors to this space are 3/4 hour fire doors instead of 1 1/2 hour B Label fire doors. The exhaust duct which passes through this space was not enclosed in a fire rated shaft. Instead fire dampers were installed at the floor penetration above and below. This condition does not comply with NFPA 90A 3-3.4.1. The fire damper at the floor penetration below lacked an access panel on 04/10/14 . The space only complies with NFPA 90A if the mechanical room is part of the shaft enclosure. Three ducts penetrate the corridor wall without fire dampers and the room does not comply with NFPA 90A 3-3.4.4.

Based on observation on the morning of 4/11/14, with the Director of Facilities, the Food Service Manager and the Safety Officer present, the surveyor finds that kitchen ventilation hood of the 3rd Floor Main Kitchen is not installed and/or maintained in accordance with NFPA 96 - 1998, ASHRAE Guidelines and State and/or National Food Service and Sanitation Regulations.

Findings include

1. The main cooking line is two cooking lines with two rows of appliances back to back with a common hood above. There are two rows of grease filters in the hood which are centered above both cooking lines. The filters are mounted in a horizontal position and are not installed at a 45 degree or greater angle in accordance with 3-2.5 of NFPA 96. The provider was not able to demonstrate have grease collection is installed in accordance with 3-2.6 and 3-2.7 of NFPA 96.

a. The provider lacked technical information which demonstrates how this hood is pre-engineered and how the filters are designed to accomplish the requirements of 3-2.5 and 1-3.5 (Alternate Methods) in accordance with NFPA 96.

b. The surveyor observed a two sided main cooking line which produced a lot of moisture from hot water and steam from cooking processes. The surveyor observed that some of this moisture was not going up the kitchen hood directly above and that the system make-up air did not appear to be working. The surveyor further observed grease and moisture dripping from the hood filters and from the stainless steel shroud below the filters.

Failure to maintain adequate ventilation could allow the build up of grease on all surfaces which could constitute a fire hazard .

Based on random observation during the survey walk-through, accompanied by two contractor foremen, the surveyor finds that not all linen or refuse chutes are constructed and maintained as fire resistive assemblies as required by 19.5.4. These deficiencies could affect all patients, staff, and visitors if a fire were to start on a different floor.

Findings include:

A. Doors to linen chutes were observed that did not carry the minimum 1 hour fire resistance rating required by 19.5.4.1. Locations observed include:

1. 10:58 AM on April 9, 2014 on 3rd floor Hamilton in the Imaging Department corridor near the CT Reading Room, the linen chute door lacked a UL label.

2. 1:24 PM on April 9, 2014 on second floor Hamilton in the Surgery Department corridor adjacent to Sterile Processing, the linen chute door lacked a UL label.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. These deficiencies could affect any patients, staff, or visitors in the areas cited because they could be prevented from reaching exits.

Findings include:

A. At 1:25 PM on April 10, 2014, while accompanied by the provider's Electrician and HVAC Specialist: Carts, furnishings, and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include (all Second Floor Surgical Department):

1. Corridor immediately north of Prep/Recovery Unit.

2. Corridor serving Operating Rooms 1, 2, 6, and 7.

3. Corridor serving Operating Rooms 3, 4, 8, and 9.

4. Corridor serving Operating Rooms 10 and 11.

A. Based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that Medical Gas Systems do not comply with NFPA 99- 1999.

Findings include

1 The 3rd Floor of the Glen Oak Building has an inpatient Dialysis Unit with oxygen, medical air and vacuum outlets at each patient station. The floor has oxygen, medical air and vacuum outlets in other outpatient treatment rooms on this floor. The oxygen shut off valves in the Dialysis room is located in the same room as the oxygen outlets and does not comply with NFPA 99, 4-3.1.2.3.

b. The provider was not able identify a zone valve which serves the medical air system for the 3rd Floor of Glen Oak in accordance with NFPA 99 4-3.1.3.2.

A. Based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that glazing in some doors do not comply with the safety glazing requirements of 16 CFR 1201.

Findings include:

1. The glazing installed in the pair of doors to the 5th Floor Glen Oak Call Center lack visible labels identifying any type of safety glazing

B. The Janitor's sink on the 4th Floor of Glen Oak is filthy and the waste pipe from above, into the sink lacks an air gap in accordance with the Plumbing Code.

C. 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:

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 random observation during the survey walk through while accompanied by the Electronics Technician, the surveyor found that the emergency electrical installation did not meet all of the requirements of NFPA-70. This could affect all occupants of the building if the emergency power system does not operate properly upon the loss of normal power.

Findings include:

1. The Crescent building was equipped with transfer switches for each branch of emergency power, but several of the panels served from the branch transfer switches were serving mixed loads as shown by some of the following examples:

a) 7th floor panel R-1S-7-174 was not listed as a life safety or critical panel, but was serving corridor and exit lighting, (life safety loads), and nurse call and receptacle loads that are critical loads.

b) 6th floor panel R-1C-6-146 is a critical panel that was serving fire alarm equipment that is required to be served from the life safety branch of emergency power

c) 5th floor, the life safety panel was serving receptacles and nurse call that are required to be served from the critical branch of emergency power, and critical panel P-3C-5-112 was serving a modular cooling unit that is required to be served from the equipment branch panel if it is to be served from the emergency power system.

d) 4th floor critical panel R-1C-4-146 was serving the elevator cab lighting that is required by Section 517-32 of NFPA-72, to be served from the life safety branch panel.

e) 3rd floor panels R1C-3-346 was serving fire alarm that is required by Section 517-32 of NFPA-70, to be served by the life safety branch panel.

f) 2nd floor life safety panel R-1S-2-130 was serving nurse call and telecom equipment that Section 517-33 of NFPA-70, requires to be served from the critical branch of emergency power. Critical panel R-1C-2-114 was serving fire alarm and elevator lights.

g) 1st floor life safety panel in the main electric room was serving duct heaters in the training room which are not allowed on the life safety branch by Section 517-32 of NFPA-70.

Items listed above are examples of the mixed loads served by the different branches of emergency power but do not constitute a full list of infractions. The surveyor observed a pattern in multiple buildings and similar problems are expected in all buildings of the hospital.

A. Based on observation with the Director of Facilities and the Safety Officer present the surveyor finds that electrical systems and materials do not comply with NFPA 70- 1999. Failure to properly identify electrical panels could result in a delay in locating and shut off electrical circuits when necessary in an emergency.

Findings include

1. The 7th Floor of the East/West Building has an electrical panel in the north corridor. It is identified with a bar code number 17130 but lacks panel identification on the outside of the panel in accordance with NFPA 70 - 1999, 384-13

A. Based on random observation during the survey walk through while accompanied by the electronics technician, the surveyor found that the elevators did not meet all of the requirements of ANSI/ASME A17.3. This could affect any occupants of the facility using the elevator if proper safety equipment is not installed on each elevator.

Findings include:

1. The elevator machine room did not have a heat detector within 2' of each sprinkler head tied to a shunt trip as required by NFPA-72, Section 3-9.4, and ASME A17.1, Section 102.2(c)(3).

2. The elevators were not equipped with elevator recall initiated by smoke detectors in the elevator machine rooms, and lobbies in accordance with ANSI A17.1/A17.3.