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Based on observation during the survey walk-through,not all doors in exit access corridors are in compliance with 18.3.6.3. This deficiency could compromise the use of the exit access corridor in the event of a fire in the space adjacent to the corridor.

Findings include:

A. At 3:45 PM on 08/13/2014 it was observed that the door to the gift shop is not separated from exit access corridors and is not equipped with positive latching hardware as required by 18.3.6.3.2.

Based on observation during the survey walk-through, not all paths of egress are lit in accordance with 19.2.8 and 7.9.1. This deficiency could affect the usability of this exit by staff and visitors in the facility basement during an emergency.

Findings include:

A. At 3:15 PM on 08/13/2014 at the egress stair serving the basement near the kitchen it was observed that the stair is illuminated by light fixtures that are controlled by a switch located in the interior exit passageway. This path of egress is not provided with an automatic means of illumination as required by 7.9.2.2.

Based on observation during the survey walk-through, the facility failed to provide a fire alarm system with approved components, devices or equipment installed according to NFPA 72. This deficiency would affect all occupants in the event of the failure of the fire alarm to operate properly during an emergency.

Findings include:

A. At 8:57 AM on 08/14/2014 at the life safety branch panel located in the Emergency Suite it was observed that the circuit breaker that feeds the fire alarm control panel is not identified with red coloration or labeling and is not provided with a mechanical lock on device as required by NFPA 72 1-5.2.5.2.

During the document review process it was observed that testing and maintenance of the fire alarm system is not documented as required by NFPA 72 and thus cannot be confirmed. Failure of the fire alarm system to operate correctly could jeopardize all occupants of the building during a fire emergency.

Findings include:

A. At 9:35 AM on 08/14/2014 during the document review process records were not available to show monthly, quarterly, and semi-annual visual inspections of fire alarm components as required by NFPA 72 1999 Table 7-3.1.

B. At 9:37 AM on 08/14/2014 during the document review process records were not available to show quarterly and semi-annual testing of fire alarm components as required by NFPA 72 1999 Table 7-3.2.

Based on observation during the survey walk-though, not all rooms are provided with sprinkler protection as required by 19.3.5. This deficiency could affect patients, staff, and visitors if a fire is not quickly extinguished and spreads to other areas of the facility.

Findings include:

A. At 8:36 AM on 08/14/2014 in the basement classroom closet it was observed that ceiling tiles were missing, which does not comply with NFPA 13 1999 5-7.4.1.1.

Based on document review, testing and maintenance of the sprinkler system is not documented as required by NFPA 25 and thus cannot be confirmed. Failure of the sprinkler system to operate correctly could jeopardize all occupants of the building during a fire emergency.

Findings include:

A. At 9:10 AM on 08/14/2014, during the document review process, records were not available to show weekly and quarterly visual inspections of sprinkler system components as required by NFPA 25 1998 Table 2-1.

B. At 9:12 AM on 08/14/2014, during the document review process, records were not available to show quarterly testing of sprinkler system components as required by NFPA 25 1998 Tables 2-1 and 9-1.

Based on observation during the survey walk-through, the facility does not maintain all fire extinguishers in accordance with NFPA 10. This deficiency could jeopardize all patients and staff in the event of a grease fire in the kitchen.

Findings include:

A. At 3:04 on 08/13/2014 it was observed that the K type fire extinguisher in the kitchen lacks the required placard directing the use of the hood fire protection system before the use of the fire extinguisher. NFPA 10 1998 2-3.2.1

Based upon random observation during the survey walk through the surveyor finds that HVAC systems do not comply with NFPA 90A 1999 and/or ASHRAE. This deficiency could jeopardize staff by allowing smoke to enter an exit access corridor.

Findings include:

A. At 8:40 AM on 08/14/2014 at the basement AC room a ducted transfer grille was observed in the exit access corridor wall, which does not comply 19.3.6.4.

Based on observation during the survey walk-through, not all cooking equipment is installed and maintained as required by NFPA 96. This deficiency could jeopardize staff and patients by allowing a grease fire to start in the kitchen.

Findings include:

A. At 3:00 PM on 08/13/2014 it was observed that the deep fat fryer is not separated from the griddle by a minimum of 16 inches as required by NFPA 96 1998 9-1.2.3.

OTHER DEFICIENCY NOT ON 2786

This STANDARD is not met as evidenced by:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the
survey walk-through, the provider shall institute the 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 observation during the survey walk-through, the facility failed to install electrical wiring in accordance with NFPA 101, 2000 Edition, Section 9.1.2 and NFPA 70, 1999 Edition, National Electrical Code. This deficiency could affect patients, staff, and visitors in the event of a failure of an outlet during a power outage.

Findings include:

A. At 3:15 PM on 08/13/2014 in the Surgery Suite it was observed that many of the outlets tied to the emergency power system are not provided with labeling that identifies the panel and circuit that supplies them.