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Based on direct observation the facility failed to install or maintain proper fireproofing as required to meet the construction type of the building. This deficiency could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection of the building structure from the effects of fire exposure can cause building collapse prior to evacuation.

Findings include:

A. On 11/17/15 at 2:10pm while accompanied by the DOF and E, the surveyor observed on 1st floor, at 3-hour rated wall by Room 157, spray-on fire proofing was removed or missing from the steel components. This does not comply with NFPA 101-2000, 19.1.6.2 and NFPA 220.




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Based on observation during the survey walk-through, the construction type of the building does not conform to non-combustible requirements. This deficiency could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection of the combustible surfaces in accordance with the manufacturers labeling instructions can expose occupants to the effects of fire and hazardous smoke.

Findings include:

B. On 11/17/15 at 9:20am in the company of BIF 1 and a MT, the surveyor observed, at the 4th floor patient room exterior walls, that unprotected pink Styrofoam insulation was exposed above the ceiling and not in compliance with 19.1.6 and the product manufacturer's labeled requirements.

Based on direct observation the facility failed to provide properly operating self closing and latching door hardware that provides separation between building compartments. This deficient practice could affect patients, staff and visitors if smoke or fire could spread without proper building separation.

Findings include:

On 11/17/15 at 1:10pm, while accompanied by the DOF, the surveyor observed the 1st floor, cross corridor 2-hour barrier doors by Human Resources Reception and elevator lobby failed to close and latch when tested during the fire alarm. The doors do not meet with the requirements of NFPA 101, Section 19.3.6.3.2 and 8.2.3.2.1.

Based on observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies and resistant to the passage of smoke. This deficiency could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments on the same floor or other floors.

Finding include:

On 11/17/15 at 9:50am while accompanied by the BIF 1 and MT, the surveyor observed on the 2nd floor of the Main Hospital the smoke barrier identified on the life safety reference plans passed through an elevator door. The elevator door is fire resistive but not resistant to the passage of smoke to comply with 19.3.7.6 and 8.3.4

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's exit access corridors.

Findings include:

A. On 11/18/15 at 8:50am while in the company of BIF 1 and MT, the surveyor observed, on the 1st floor of the Main Hospital, the Soiled Utility room door at the Cath Lab suite did not self-close to a latched condition to comply with 19.3.2.1.

B. On 11/18/15 at 9:45am while in the company of BIF 1 and MT, the surveyor observed, on the Lower Level of the Main Hospital, the Kitchen Dry Storage Room NW door was not self-closing to a latched condition to comply with 19.3.2.1.

1. A pipe penetration above this door was not sealed in accordance with a UL tested assembly.

C. On 11/18/15 at 9:45am while in the company of BIF 1 and MT, the surveyor observed, on the Lower Level of the Main Hospital, the Kitchen Dry Storage room NE pair of doors was not latching to comply with 19.3.2.1.

D. On 11/18/15 at 10:00am on 11/18/15 while in the company of BIF 1 and MT, the surveyor observed, on the Lower Level of the Main Hospital, the two Catering Storage room corridor doors had dead bolt locks only which does not provide positive latching to comply with 19.3.2.1 and 19.3.6.3.2.

Based on observation, two separated exits are not provided from every floor level. Failure to provide two exits can prevent occupants from evacuating the building in the event the only available exit is compromised.

Findings include:

On 11/18/15 at 11:15am during review of the life safety reference plans, the sureyor determined the fifth floor office penthouse floor level has only a single exit in non-compliance with 19.2.4.1 or 39.2.4.2.

Based on observation during the survey walk-through, not all exits are enclosed with construction having a fire resistance rating. These deficiencies could affect any patients in the facility that must utilize the exit, as well as any staff and visitors present by compromising the required protection of the exit enclosure and preventing those occupants from reaching an exit from the building.

Findings include:

On 11/16/15 at 2:25pm on 11/16/15 while accompanied by the BIF 1 and MT, the surveyors observed, at the 6th floor of the Main Hospital building, the Stair B door was missing the fire resistance rating label to confirm the door's rating. This does not comply with 19.3.1.1, 8.2.5.2 and 7.1.3.2.1(a).

Based on observation during the survey walk-through, not all exit access doors are arranged so that exits are readily accessible at all times. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. On 11/17/15 starting at 10:10am, while in the company of BIF 1 and a MT, the surveyor observed in the Main Hospital Building, egress doors that are equipped with magnetic locking devices that are not in compliance with the general requirements of 7.2.1.6.1 relative to the building not being fully detected or fully sprinklered and 7.2.1.6.1(d)

Locations include:

1. Stair doors on the 2nd floor OB Unit are provided with delayed egress locking devices.

2. The cross corridor doors within the OB unit near the entrance adjacent the elevator.

3. The south wing exit from the 2nd floor OB unit had two delayed egress locking devices in this path. One at the inside corridor door and one at the glass door at the exterior stair.

4. The 2nd floor entry to the OB unit adjacent the public elevator was locked with a non-delayed egress locking device. The locked door was not in compliance with 19.2.2.2.4.

5. The 1st floor MRI suite corridor doors are equipped with delayed egress magnetic locking devices which function as the latching system. The delayed egress function was not operating in accordance with 7.2.1.6.1. The doors lack positive latching under all conditions to comply with 19.3.6.3.2.

B. The Lower Level Dining room pairs of doors (minimum 3 pair) were equipped with panic device hardware and astragals. This arrangement does not comply with 7.2.1.5.5.

C. The 1st floor Emergency Room Waiting room is provided with exit signage which directs the exit access into the Emergency room suite which does not comply with 19.2.5.9 and 7.5.1.2.

D. The Chapel corridor door was equipped with a key-only operated dead bolt lock which can be engaged to prevent egress which does not comply with 19.2.2.2.4 and 7.2.1.5.4.

Based on direct observation the facility failed to provide exit signs that were fully visible, or correctly identifying paths of egress. These deficiencies could affect all patients, visitors or staff within the areas of the facility from readily identifying paths to an available exit from the building.

Findings include:

On 11/17/15 at 1:05pm, while accompanied by the DOF during the fire alarm testing, the surveyor observed on the 1st floor, at the cross corridor doors by the Human Resources Reception and elevator, the space lacked any exit signs to identify the appropriate egress path. The lack of signage fails to meet with NFPA 101, 2000 19.2.10.1 and 7.10.1.2.

Based on document review and staff interview, fire drills are not conducted in a compliant manner. These deficiencies could affect any patients, staff, or visitors in the building because the fire alarm system may not function properly under emergency conditions.

Findings include:

On 11/16/15 at 12:48pm during an interview with the FM, the surveyor determined from the review of fire drill records that fire drills conducted between the hours of 9:00pm and 6:00am do not include the transmission of a fire alarm signal as required by 18.7.1.2.

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed and maintained as required. These deficiencies could affect any patients, staff, or visitors in the building because the fire alarm system may fail to function properly during fire emergencies.

A. While accompanied by the DOF the surveyor observed that several smoke detectors are located in the supply air stream which does not meet with NFPA 72, 1999, 2-3.5.1. Findings include:

1. On 11/17/15 at 2:35pm, 1st floor conference room.

2. On 11/17/15 at 3:00pm, 1st floor, Administration - Kevin ' s office.

3. On 11/17/15 at 3:05pm, 1st floor, Administration - Grace ' s office.

4. On 11/18/15 at 9:35am, Lower level, Room TL 154 (Jo Ann ' s old office).

5. On 11/18/15 at 10:00am, Lower level, Dialysis storage Office



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B. On 11/17/15 at 10:10am while in the company of BIF 1 and a MT , the surveyor observed, on the 2nd floor of the Main Hospital, the IT room adjacent to the elevators lacked ceiling tile to permit the fire detection and sprinkler system to function as required. The fire detection and sprinkler head components were located at the partial tile ceiling level and not at the top of the room to comply with NFPA 72-1999, 2-3.4.3.1 and NFPA 13-1999, 5-6.4.1.

C. On 11/18/15 at 8:55am in the company of BIF 1 and MT, the surveyor observed fire detection and sprinkler system components were not installed in accordance with NFPA 72-1999. 2-3.4.3.1 and NFPA 13-1999, 5-6.4.1
Locations observed include:

1. The detector at the 1st floor Cath Lab 10 electrical closet.

2. The sprinkler head at the Lower Level Janitor closet near Stair F.

3. The sprinkler head at the electric closet within the Lower Level Library.

4. The detector at the electric closet south of the Dining room adjacent Stair D.

5. The detectors in the Lower Level corridor which connects to the tunnels.



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D. On 11/17/15 at 1:31pm while accompanied by the BIF 2, during a test of the building fire alarm system, the surveyor observed more than two visual notification (strobe) devices, less than 55'-0" apart, which are not synchronized as required by NFPA 72 1999 4-4.4.2.2, from the Second Floor Mother/Baby Unit Nurses' Station.

Based on observation during the survey walk-through, Rubbish chutes are not maintained. Failure to maintain the fire resistive enclosure of the chutes can expose multiple floors to fire & smoke conditions when chute access doors are not maintained.

Findings include:

On 11/17/15 at 9:35am while in the company of BIF 1 and a MT, the surveyor observed the rubbish chute access door located on the 3rd floor of the Main Hospital building was not self-closing to a latched condition to comply with NFPA 101-2000, 9.5.1.

Based on direct observations the facility failed to provide exit routes that are readily accessible to a public-way at all times. This deficient practice could affect patients, staff and visitors if during an evacuation or facility disaster that equipment or furniture in the corridors hinders the process.

Findings include:

On 11/17/15 at 2:20pm, while accompanied by the DOF, the surveyor observed on the 1st floor, small wheeled carts with personal protective equipment (gloves, gowns, etc.) were located in the corridor outside every ICU patient room door. This does not meet with NFPA 101, 19.2.1 or 7.1.10.

Based on observation during the survey walk-through, not all portions of the building piped medical gas system are installed in accordance with code. Failure to install medical gas systems in accordance with requirements can result in failure of the system to perform without hazard to the occupants.

Findings include:

On 11/18/15 at 10:15am while in the company of BIF 1 and a MT, the surveyor observed, in the Lower Level corridor of the Main Hospital Building, the medical gas piping supported from iron trapeze hangers does not have the lead sheet separator (or insulated fastener) between all copper lines and the iron hangers to provide the separation of dissimilar metals required by NFPA 99-1999, 4-3.1.2.9.

Based on 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.

Based on observations made during the survey walk through 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:

A. On 11/17/15 at 9:15am while in the company of BIF 1 and MT, the surveyor observed the building was equipped with enough 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:

1. Critical panel CLR4-H-7 on the 4th floor served a mixture of Critical loads and Life Safety loads (Emergency lighting), that are required by the 1999 edition of NFPA-70, Sections 517-30 through 517-35 to be served from separate branches.

Surveyor: Vondebur, Thomas

B. On 11/17/15 at 9:30am while in the company of the MS, the surveyor observed the building was equipped with enough 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:

2. Panels ELL1-H-7 located in the first floor electrical closet, and ELL2-H-7 located in the 2nd floor electrical closet were serving both life safety and critical loads and did not comply with the 1999 edition of NFPA-70, Sections 517-32 and 517-33.

3. The critical distribution panel CDPB-A-1B in the basement electrical room of the Main Hospital building was serving elevators. If elevators are served from emergency power, they are required to be served from the equipment branch in accordance with NFPA-70, Section 517-34.














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Based on observation, the electrical wiring and equipment is not installed in accordance with code. Failure to install and maintain the electrical system could result in failure of the system to operate when needed.

Findings include:

A. On 11/18/15 at 2:35pm while in the company of the BIF 1 and MT, the surveyor observed, on the 1st floor of the Main Hospital building, the Emergency Dept. treatment rooms have red receptacles for critical care beds which are not labeled to identify the panel and circuit from which they are fed to comply with NFPA 70-1999, 517-19(a).


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B. On 11/16/15 at 2:30pm while accompanied by the MS, the surveyor observed the elevator cab lights in elevators A, B, C and D were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32, and the elevators were not equipped with cab lighting disconnects in the elevator equipment rooms in accordance with NFPA-70, Section 620-53.

C. On 11/17/15, at 10:30am while accompanied by the MS, the surveyor observed the C-section room in the Main Hospital was not equipped with receptacles served from a normal source of power or a second transfer switch to meet the requirements of the 1999 Edition of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.