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Based on observation, not all egress doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress under emergency conditions could be impeded if they are not maintained

Findings include:

On November 28, 2017 at 12:52 PM, while accompanied by the DSS, observation determined that the door from the Courtyard into the building can be secured against egress, in a manner prohibited by 19.2.2.2.5.1, because the door can be secured so that a key is required for re-entry.

Based on observation, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

On November 28, 2017 at 1:10 PM, while accompanied by the DSS, observation determined that the egress path at the west end of the South Patient Sleeping Room Corridor is not identified by an exit sign, at the east side of the cross-corridor doors, as required by 7.10.1.1.

Based on observation during the survey walk-through, the facility failed to provide and maintain fire extinguishers as required. This deficient practice could affect any patients, staff, and visitors in the immediate area by preventing the extinguishment of a fire if the fire extinguishers do not function properly

Findings include:

On November 28, 2017 at 11:24 AM, while accompanied by the DSS, observation determined that the Employee Appreciation Kitchenette lacks a fire extinguisher required by NFPA 10, 2010 Table 6.2.1.1.

Based on observation, not all smoke barriers are constructed and maintained as required. This deficient practice could affect any patients, staff, and visitors in the building because smoke could pass between adjacent smoke compartments if the smoke barriers are not properly constructed.

Findings include:

On November 28, 2017 at 1:21 PM, while accompanied by the DSS, observation determined that the cross-corridor doors in the smoke barrier wall between the Surgery Department and the Laboratory did not completely close, as required by 19.3.7.8(1) and NFPA 105 2010 4.5.1, upon activation of the building fire alarm system.

Based on observation, the facility failed to install and maintain its piped-in medical gas system in the manner required. This deficient practice could affect any patients, staff, and visitors in the building because the medical gas piping system could fail to operate when needed if not properly installed and maintained.

Findings include:

On November 28, 2017 at 11:37 AM, while accompanied by the DSS, observation determined that pipes which penetrate the 1 hour fire rated walls of the Medical Gas Manifold Room are not sealed against the passage of fire as required by 8.3.5.1 and NFPA 99 2012 5.1.3.3.2(4). Pipes observed include:

A. Two sprinkler pipes (north wall).

B. Five medical gas or other copper pipes (also north wall).

Based on observation, the facility is not provided with the appropriate level of Essential Electrical System. This deficient practice could affect any patients, staff, and visitors in the building because the Essential Electrical System could fail to operate under emergency conditions if it is not consistent with the level of care being provided to patients.

Findings include:

On November 28, 2017 at 11:30 AM, while accompanied by the DSS, observation determined that the starter batteries for the emergency generator lack a battery heater required by NFPA 110 2010 5.3.1.