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Based on observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

On May 18, 2015, at 11:09 AM, while accompanied by the provider's Director of Plant Operations, the surveyor observed a pair of cross-corridor doors, in a designated 2 hour wall directly west of the exterior doors to the Smoking Patio, could not be determined to carry a minimum 90 minute fire rating required by 8.2.3.2.3.1(1) because the attached label stated that, although the door was manufactured with the same materials as rated doors, the user had requested changes which caused the doors to not be able to carry a fire rating label issued by either UL or Warnock-Hersey.

Based on 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. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

A. On May 18, 2015, while accompanied by the provider's Director of Plant Operations, the surveyor observed egress paths that are not identified by exit signs as required by 7.10.1.1. Locations observed include:

1. 11:00 AM: No exit sign was observed above the south side of the cross-corridor door adjacent to the Dietary Manager's Office, which directs building occupants toward the north.
2. 11:05 AM: No exit sign was observed above the east side of the door to the Cafeteria, which directs building occupants toward the west.

Based on observation during the survey walk-through and staff interview, the building's emergency generator is not installed and maintained in accordance with NFPA 99. These deficiencies could affect any patients, staff, or visitors in the hospital because the emergency generator could fail to operate under emergency conditions.

Findings include:

A. On May 18, 2015, at 10:40 AM, while accompanied by the Director of Plant Operations, the surveyor observed the emergency generator lacks a remote manual stop station required by NFPA 110 1999 3-5.5.6. During an interview held at that time, the provider's Director of Plant Operations confirmed this observation.

B. On May 18, 2015, at 10:41 AM, while accompanied by the Director of Plant Operations, the surveyor observed the starter batteries for the emergency generator lack an automatically controlled heater required by NFPA 110 1999 3-3.1. During an interview held at that time, the provider's Director of Plant Operations confirmed this observation.

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 observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any patients being treated in the cited areas because normal power may not be available under certain conditions.

Findings include:

A. On May 18, 2015, at 11:25 AM, while accompanied by the provider's Director of Plant Operations, the surveyor observed critical care patient beds at which 1 circuit is not from the building's normal electrical system as required by NFPA 70 1999 517-18(a). Locations observed include:

1. Exam Room 1.

2. Exam Room 2.

3. Trauma Room.

Based on observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

On May 18, 2015, at 11:09 AM, while accompanied by the provider's Director of Plant Operations, the surveyor observed a pair of cross-corridor doors, in a designated 2 hour wall directly west of the exterior doors to the Smoking Patio, could not be determined to carry a minimum 90 minute fire rating required by 8.2.3.2.3.1(1) because the attached label stated that, although the door was manufactured with the same materials as rated doors, the user had requested changes which caused the doors to not be able to carry a fire rating label issued by either UL or Warnock-Hersey.

Based on 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. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

A. On May 18, 2015, while accompanied by the provider's Director of Plant Operations, the surveyor observed egress paths that are not identified by exit signs as required by 7.10.1.1. Locations observed include:

1. 11:00 AM: No exit sign was observed above the south side of the cross-corridor door adjacent to the Dietary Manager's Office, which directs building occupants toward the north.
2. 11:05 AM: No exit sign was observed above the east side of the door to the Cafeteria, which directs building occupants toward the west.

Based on observation during the survey walk-through and staff interview, the building's emergency generator is not installed and maintained in accordance with NFPA 99. These deficiencies could affect any patients, staff, or visitors in the hospital because the emergency generator could fail to operate under emergency conditions.

Findings include:

A. On May 18, 2015, at 10:40 AM, while accompanied by the Director of Plant Operations, the surveyor observed the emergency generator lacks a remote manual stop station required by NFPA 110 1999 3-5.5.6. During an interview held at that time, the provider's Director of Plant Operations confirmed this observation.

B. On May 18, 2015, at 10:41 AM, while accompanied by the Director of Plant Operations, the surveyor observed the starter batteries for the emergency generator lack an automatically controlled heater required by NFPA 110 1999 3-3.1. During an interview held at that time, the provider's Director of Plant Operations confirmed this observation.

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 observation during the survey walk-through, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any patients being treated in the cited areas because normal power may not be available under certain conditions.

Findings include:

A. On May 18, 2015, at 11:25 AM, while accompanied by the provider's Director of Plant Operations, the surveyor observed critical care patient beds at which 1 circuit is not from the building's normal electrical system as required by NFPA 70 1999 517-18(a). Locations observed include:

1. Exam Room 1.

2. Exam Room 2.

3. Trauma Room.