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Based on observation, the facility failed to provide adequate corridor protection. This condition could affect patients and staff during a fire smoke event by exposing the means of egress to a room of fire origin.

Finding includes:

On August 16, 2016 at 1:30 pm while accompanied by BE & E, the surveyor observed patient sleeping room 134 did not have a door to separate it from the common corridor area to comply with 19.3.6.3.1.

Based on observation the facility failed to provide adequate corridor protection. This condition could affect patients and staff during a fire smoke event by exposing the means of egress to a room of fire origin.

Finding includes:

A. On August 16, 2016 at 11:10 am while accompanied by BE, the surveyor observed a dutch door which did not provide latching between the upper and lower leafs. There was no astragal, or bevel at the meeting edge of the upper and lower leaf. These conditions do not comply with 19.3.6.3.6.

Location observed: Nurse Station

Based on observation, the surveyor finds the facility failed to provide adequate separation between floors. This condition could allow the spread of fire and smoke between building levels which will affect all patient areas.
Findings include:
On August 16, 2016 at 1:30pm while accompanied by the BE & E, the surveyor observed multiple through floor duct penetrations (at walls and ceiling of the basement level) to the patient floor above. The installations do not comply with 3-3.2 of NFPA 90A-1999 for fire dampers and access panels.

Based on observation, the surveyor finds the facility failed to provide adequate separation between floors. This condition could allow the spread of fire and smoke between building levels which will affect all patient areas.
Findings include:
On August 16, 2016 at 2:30pm while accompanied by the BE & E, the surveyor observed multiple through floor duct penetrations (at walls and ceiling of the basement level) to the patient floor above. The installations do not comply with 3-3.4.4 of NFPA 90A-1999 for fire dampers and access panels.

Based on observation, the surveyor finds the facility failed to provide adequate separation between floors. This condition could allow the spread of fire and smoke between building levels which will affect all patient areas.
Findings include:
On August 16, 2016 at 3:00 pm while accompanied by the BE & E, the surveyor observed multiple through floor duct penetrations (at walls and ceiling of the basement level) to the patient floor above. The installations do not comply with 3-3.2 of NFPA 90A-1999 for fire dampers and access panels.

A. Based on observation, the surveyor finds the facility failed to provide adequate separation between floors. This condition could allow the spread of fire and smoke between building levels which will affect all patient areas.
Findings include:
1. On August 16, 2016 at 2:30pm while accompanied by the CBE, the surveyor observed multiple through floor duct penetrations (at walls and ceiling of the basement level) to the patient floor above. The installations do not comply with 3-3.2 of NFPA 90A-1999 for fire dampers and access panels.

A. Based on observation, the surveyor finds the facility failed to provide adequate separation between floors. This condition could allow the spread of fire and smoke between building levels which will affect all patient areas.
Findings include:
1. On August 16, 2016 at 2:30pm while accompanied by the CBE. the surveyor observed multiple through floor duct penetrations (at walls and ceiling of the basement level) to the patient floor above. The installations do not comply with 3-3.2 of NFPA 90A-1999 for fire dampers and access panels.

A. Based on observation, the surveyor finds the facility failed to provide adequate separation between floors. This condition could allow the spread of fire and smoke between building levels which will affect all patient areas.
Findings include:
1. On August 17, 2016 at 10:30am while accompanied by the CBE. the surveyor observed multiple through floor duct penetrations (at walls and floor of the basement level) to the patient floor above. The installations do not comply with 3-3.2 of NFPA 90A-1999 for fire dampers and access panels.

Based on observation the facility failed to install directional EXIT signs. This deficiency could affect all patients, undeterminable number of staff and visitors if the exits cannot be located.

Findings include:

A. On August 16, 2016 at 11:15 am, while accompanied by the CBE and BE, the surveyors observed chevrons on directional EXIT signs that are not installed to comply with 19.2.10.1 and 7.10 to indicate the proper means of egress to an exit.

Location observed:
The exit sign adjacent to vestibule door leading to the fenced courtyard.

Based on observation and staff interview, the surveyors find that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 16, 2016 at 1:50 pm, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview, the surveyors find that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 16, 2016 at 2:15 pm, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview, the surveyors find that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 16, 2016 at 3:15pm, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview, the surveyors finds that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 16, 2016 at 12:15 pm, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview, the surveyors finds that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 17, 2016 at 10:25 am, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview, the surveyors finds that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 17, 2016 at 9:15am, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview, the surveyors finds that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 16, 2016 at 11:50 am, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview during the survey walk-through, not all exit discharge locations are provided with emergency illumination. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On August 16, 2016 at 1:45 pm, while accompanied by the BE & E, the surveyors observed exterior building mounted lighting provided, at the exit discharge doors and breezeways, were not of an instant-on type to provide illumination within 10 seconds of loss of the normal power supply to comply with 19.2.8.1, 7.8.1.4 & 7.9.1.2.

Based on observation and staff interview during the survey walk-through, not all exit discharge locations are provided with emergency illumination. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On August 16, 2016 at 2:30 pm, while accompanied by the BE & E, the surveyors observed exterior building mounted lighting provided at the exit discharge doors and breezeways which were not of an instant-on type to provide illumination within 10 seconds of loss of the normal power supply to comply with 19.2.8.1, 7.8.1.4 & 7.9.1.2. Lighting was indicated to be metal halide and/or High Pressure Sodium type.

Based on observation and staff interview during the survey walk-through, not all exit discharge locations are provided with emergency illumination. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On August 16, 2016 at 3:10 pm, while accompanied by the BE & E, the surveyors observed exterior building mounted lighting provided at the exit discharge doors and breezeways which were not of an instant-on type to provide illumination within 10 seconds of loss of the normal power supply to comply with 19.2.8.1, 7.8.1.4 & 7.9.1.2. Lighting was indicated to be metal halide and/or High Pressure Sodium type.

Based on observation and staff interview during the survey walk-through, not all exit discharge locations are provided with emergency illumination. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On August 16, 2016 at 1:45 pm, while accompanied by the CBE & BE, the surveyors observed exterior building mounted lighting provided at the exit discharge doors and breezeways which were not of an instant-on type to provide illumination within 10 seconds of loss of the normal power supply to comply with 19.2.8.1, 7.8.1.4 & 7.9.1.2. Lighting was indicated to be metal halide and/or High Pressure Sodium type.

Based on observation and staff interview during the survey walk-through, not all exit discharge locations are provided with emergency illumination. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On August 17, 2016 at 9:45 pm, while accompanied by the CBE & BE, the surveyors observed exterior building mounted lighting provided at the exit discharge doors and breezeways which were not of an instant-on type to provide illumination within 10 seconds of loss of the normal power supply to comply with 19.2.8.1, 7.8.1.4 & 7.9.1.2. Lighting was indicated to be metal halide and/or High Pressure Sodium type.

Based on observation during the survey walk-through, and document review, the facility's written plan for the protection of patients is not completely accurate. These deficiencies could affect any patients, staff, or visitors in the building because the failure to identify key life safety components could result in the failure to protect them properly.

Findings include:

On August 17, 2016 at 11:00am while in the company of the CBE & SO during review of the facility's written fire plan it was observed that the plan did not accurately reflect all conditions present at this facility.

Examples include:

A. The written plan indicates under "Objectives" paragraph 5, and in numerous other locations within the written plan regarding fire drills, that "at least 50% are unannounced". All drills are to be "unannounced" to comply with the requirements that drills be conducted at unexpected times under varying conditions to comply with 19.7.1.2.

B. The written plan indicates under LS.02.01.20 that egress doors are unlocked. This facility uses the provisions of 19.2.2.2.2 Exception No.2 to permit locking of means of egress doors for the clinical need of patients. Therefore, all egress doors are not unlocked.

C. The written plan contains reference to Life Safety Code requirements which may not be applicable to this facility based upon building configuration and characteristics. References to multiple floor levels, exit stairs and smoke barriers are not applicable for the one story, patient pavilion buildings which have no smoke barrier compartmentalization due to their 28 bed capacity.

Based on direct observation during the survey walk-through, the facility failed to provide a fire alarm system with approved components, devices or equipment installed in accordance with code. This deficiency could affect patients, staff and visitors if there was an inadvertant disconnection of the fire alarm system's power supply to prevent the fire alarm from functioning.

Findings include:

On August 16, 2016 at 2:35 pm while in the company of a BE & E, the surveyors observed, at the basement mechanical room at Panel EM-3, that the circuit serving the fire alarm panel was not provided with a mechanical lock-on device as required by NFPA 72 1999 1-5.2.5.2.

Based on direct observation during the survey walk-through, the facility failed to provide a fire alarm system with approved components, devices or equipment installed in accordance with code. This deficiency could affect patients, staff and visitors if there was an inadvertant disconnection of the fire alarm system's power supply to prevent the fire alarm from functioning.

Findings include:

On August 16, 2016 at 3:05 pm while in the company of a BE & E, the surveyors observed at the basement mechanical room at Panel EM-5 that the circuit serving the fire alarm panel was not provided with red markings and was not provided with a mechanical lock-on device as required by NFPA 72 1999 1-5.2.5.2.

Based on direct observation during the survey walk-through, the facility failed to provide a fire alarm system with approved components, devices or equipment installed in accordance with the code. This deficiency could affect patients, staff and visitors if there was an inadvertant disconnection of the fire alarm system's power supply to prevent the fire alarm from functioning.

Findings include:

On August 16, 2016 at 1:55 pm while in the company of a BE & E, the surveyors observed, at the basement mechanical room at Panel EM-1, the circuit serving the fire alarm panel was not provided with a mechanical lock-on device as required by NFPA 72 1999 1-5.2.5.2. The panel directory marked "fire alarm" was marked through but the circuit was turned on.

Based on observation the facility failed to provide adequate sprinkler protection in all areas of the buildings.These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

A. On August 16, 2016 at 1:46pm while accompanied by CBE, the surveyors observed sprinkler heads located less than 6 feet apart. This condition does not comply with NFPA 13 1999 5-6.3.4.

Location observed: laundry room

Based on observation the facility failed to provide adequate sprinkler protection in all areas of the buildings. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

A. On August 16, 2016 at 2:46pm while accompanied by CBE the surveyors observed sprinkler heads located less than 6 feet apart. This condition does not comply with NFPA 13 1999 5-6.3.4.

Location observed: laundry room

Based on observation the facility failed to provide adequate sprinkler protection in all areas of the buildings.. This condition could affect sprinkler coverage and the protection of patients and staff during a fire and smoke event. not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

A. On August 16, 2016 at 1:46pm while accompanied by CBE the surveyors observed sprinkler heads located less than 6 feet apart. This condition does not comply with NFPA 13 1999 5-6.3.4.

Location observed: laundry room

Based on observation the facility failed to provide adequate sprinkler protection in all areas of the buildings.. This condition could affect sprinkler coverage and the protection of patients and staff during a fire and smoke event. not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

A. On August 17, 2016 at 10:46am while accompanied by CBE the surveyors observed sprinkler heads located less than 6 feet apart. This condition does not comply with NFPA 13 1999 5-6.3.4.

Location observed: laundry room

Based on observation, the facility failed to maintain a proper emergency power system. If the generator catches fire, emergency personnel would be at greater risk without a remote shut of of the generator.

Findings Include:

On 8/16/16 at 2:05 PM, while accompanied by the BE and E, the surveyor observed the emergency generators are not equipped with a remote stop switch in accordance with the 1999 Edition of NFPA-110, Section 3-5.5.6.

Based on observation, the facility failed to maintain a proper emergency power system. If the generator fails to operate upon the loss of normal power, this could affect all occupants of the building.

Findings Include:

On 8/17/16 at 11:00 AM, while accompanied by the BE and E, the surveyor observed the emergency generator annunciator is not located at a 24 hour staffed location in accordance with the 1999 addition of NFPA-110, Section 3-5.6.1.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/16/16 at 1:00 PM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/16/16 at 1:20 PM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/16/16 at 1:55 PM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/16/16 at 2:25 PM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/16/16 at 2:50 PM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/17/16 at 8:30 AM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/17/16 at 9:05 AM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/17/16 at 9:35 AM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/17/16 at 9:55 AM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based upon survey walk-through direct observation, electrical systems are not installed in accordance with requirements in all areas. Failure to provide proper electrical installations can result in electrical shock hazards to occupants.

Findings include:

A. On August 16, 2016 at 3:10 pm while in the company of the BE & E it was observed that electrical duplex outlets adjacent the sink in the Laundry and Janitor rooms could not be confirmed to be GFCI protected to comply with NFPA 70-1999, 210-8(b). Although GFCI breakers were observed in the building electrical panel, the directory did not clearly identify these outlets as GFCI.

B. On August 16, 2016 at 3:15pm while in the company of the BE & E it was observed that building electrical panel "B" lacked an accurate or complete panel directory to identify all circuits to comply with NFPA 70-1999, 384-13. Two 2-pole breakers were turned ON but their use could not be determined by observation or staff interview.

Based on observation, the facility failed to provide adequate corridor protection. This condition could affect patients and staff during a fire smoke event by exposing the means of egress to a room of fire origin.

Finding includes:

On August 16, 2016 at 1:30 pm while accompanied by BE & E, the surveyor observed patient sleeping room 134 did not have a door to separate it from the common corridor area to comply with 19.3.6.3.1.

Based on observation the facility failed to provide adequate corridor protection. This condition could affect patients and staff during a fire smoke event by exposing the means of egress to a room of fire origin.

Finding includes:

A. On August 16, 2016 at 11:10 am while accompanied by BE, the surveyor observed a dutch door which did not provide latching between the upper and lower leafs. There was no astragal, or bevel at the meeting edge of the upper and lower leaf. These conditions do not comply with 19.3.6.3.6.

Location observed: Nurse Station

Based on observation, the surveyor finds the facility failed to provide adequate separation between floors. This condition could allow the spread of fire and smoke between building levels which will affect all patient areas.
Findings include:
On August 16, 2016 at 1:30pm while accompanied by the BE & E, the surveyor observed multiple through floor duct penetrations (at walls and ceiling of the basement level) to the patient floor above. The installations do not comply with 3-3.2 of NFPA 90A-1999 for fire dampers and access panels.

Based on observation, the surveyor finds the facility failed to provide adequate separation between floors. This condition could allow the spread of fire and smoke between building levels which will affect all patient areas.
Findings include:
On August 16, 2016 at 2:30pm while accompanied by the BE & E, the surveyor observed multiple through floor duct penetrations (at walls and ceiling of the basement level) to the patient floor above. The installations do not comply with 3-3.4.4 of NFPA 90A-1999 for fire dampers and access panels.

Based on observation, the surveyor finds the facility failed to provide adequate separation between floors. This condition could allow the spread of fire and smoke between building levels which will affect all patient areas.
Findings include:
On August 16, 2016 at 3:00 pm while accompanied by the BE & E, the surveyor observed multiple through floor duct penetrations (at walls and ceiling of the basement level) to the patient floor above. The installations do not comply with 3-3.2 of NFPA 90A-1999 for fire dampers and access panels.

A. Based on observation, the surveyor finds the facility failed to provide adequate separation between floors. This condition could allow the spread of fire and smoke between building levels which will affect all patient areas.
Findings include:
1. On August 16, 2016 at 2:30pm while accompanied by the CBE, the surveyor observed multiple through floor duct penetrations (at walls and ceiling of the basement level) to the patient floor above. The installations do not comply with 3-3.2 of NFPA 90A-1999 for fire dampers and access panels.

A. Based on observation, the surveyor finds the facility failed to provide adequate separation between floors. This condition could allow the spread of fire and smoke between building levels which will affect all patient areas.
Findings include:
1. On August 16, 2016 at 2:30pm while accompanied by the CBE. the surveyor observed multiple through floor duct penetrations (at walls and ceiling of the basement level) to the patient floor above. The installations do not comply with 3-3.2 of NFPA 90A-1999 for fire dampers and access panels.

A. Based on observation, the surveyor finds the facility failed to provide adequate separation between floors. This condition could allow the spread of fire and smoke between building levels which will affect all patient areas.
Findings include:
1. On August 17, 2016 at 10:30am while accompanied by the CBE. the surveyor observed multiple through floor duct penetrations (at walls and floor of the basement level) to the patient floor above. The installations do not comply with 3-3.2 of NFPA 90A-1999 for fire dampers and access panels.

Based on observation the facility failed to install directional EXIT signs. This deficiency could affect all patients, undeterminable number of staff and visitors if the exits cannot be located.

Findings include:

A. On August 16, 2016 at 11:15 am, while accompanied by the CBE and BE, the surveyors observed chevrons on directional EXIT signs that are not installed to comply with 19.2.10.1 and 7.10 to indicate the proper means of egress to an exit.

Location observed:
The exit sign adjacent to vestibule door leading to the fenced courtyard.

Based on observation and staff interview, the surveyors find that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 16, 2016 at 1:50 pm, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview, the surveyors find that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 16, 2016 at 2:15 pm, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview, the surveyors find that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 16, 2016 at 3:15pm, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview, the surveyors finds that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 16, 2016 at 12:15 pm, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview, the surveyors finds that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 17, 2016 at 10:25 am, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview, the surveyors finds that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 17, 2016 at 9:15am, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview, the surveyors finds that the facility failed to provide compliant paths of egress to the public way. This deficient practice could affect the patients, staff and visitors exiting the building during a fire emergency.
Findings Include:
On August 16, 2016 at 11:50 am, while accompanied by the BE & E, the surveyors observed exterior exit paths which do not comply with 19.2.7, 7.7.1, 7.1.6 and 7.1.10 due to the following:
A. From the courtyard side, neither gate is identified as to which or both are part of the means of egress leading to the public way. This condition does not comply with 19.2.10.1 for the marking of a means of egress.
B. Due to the heaving and movement of patio stones and uneven grassed surfaces, all providing tripping hazards and prevent maintenance under all weather conditions, the exit paths through the fenced courtyards do not comply with 7.1.6.1 and 7.1.10 for walking surface requirements.

Based on observation and staff interview during the survey walk-through, not all exit discharge locations are provided with emergency illumination. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On August 16, 2016 at 1:45 pm, while accompanied by the BE & E, the surveyors observed exterior building mounted lighting provided, at the exit discharge doors and breezeways, were not of an instant-on type to provide illumination within 10 seconds of loss of the normal power supply to comply with 19.2.8.1, 7.8.1.4 & 7.9.1.2.

Based on observation and staff interview during the survey walk-through, not all exit discharge locations are provided with emergency illumination. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On August 16, 2016 at 2:30 pm, while accompanied by the BE & E, the surveyors observed exterior building mounted lighting provided at the exit discharge doors and breezeways which were not of an instant-on type to provide illumination within 10 seconds of loss of the normal power supply to comply with 19.2.8.1, 7.8.1.4 & 7.9.1.2. Lighting was indicated to be metal halide and/or High Pressure Sodium type.

Based on observation and staff interview during the survey walk-through, not all exit discharge locations are provided with emergency illumination. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On August 16, 2016 at 3:10 pm, while accompanied by the BE & E, the surveyors observed exterior building mounted lighting provided at the exit discharge doors and breezeways which were not of an instant-on type to provide illumination within 10 seconds of loss of the normal power supply to comply with 19.2.8.1, 7.8.1.4 & 7.9.1.2. Lighting was indicated to be metal halide and/or High Pressure Sodium type.

Based on observation and staff interview during the survey walk-through, not all exit discharge locations are provided with emergency illumination. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On August 16, 2016 at 1:45 pm, while accompanied by the CBE & BE, the surveyors observed exterior building mounted lighting provided at the exit discharge doors and breezeways which were not of an instant-on type to provide illumination within 10 seconds of loss of the normal power supply to comply with 19.2.8.1, 7.8.1.4 & 7.9.1.2. Lighting was indicated to be metal halide and/or High Pressure Sodium type.

Based on observation and staff interview during the survey walk-through, not all exit discharge locations are provided with emergency illumination. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

On August 17, 2016 at 9:45 pm, while accompanied by the CBE & BE, the surveyors observed exterior building mounted lighting provided at the exit discharge doors and breezeways which were not of an instant-on type to provide illumination within 10 seconds of loss of the normal power supply to comply with 19.2.8.1, 7.8.1.4 & 7.9.1.2. Lighting was indicated to be metal halide and/or High Pressure Sodium type.

Based on observation during the survey walk-through, and document review, the facility's written plan for the protection of patients is not completely accurate. These deficiencies could affect any patients, staff, or visitors in the building because the failure to identify key life safety components could result in the failure to protect them properly.

Findings include:

On August 17, 2016 at 11:00am while in the company of the CBE & SO during review of the facility's written fire plan it was observed that the plan did not accurately reflect all conditions present at this facility.

Examples include:

A. The written plan indicates under "Objectives" paragraph 5, and in numerous other locations within the written plan regarding fire drills, that "at least 50% are unannounced". All drills are to be "unannounced" to comply with the requirements that drills be conducted at unexpected times under varying conditions to comply with 19.7.1.2.

B. The written plan indicates under LS.02.01.20 that egress doors are unlocked. This facility uses the provisions of 19.2.2.2.2 Exception No.2 to permit locking of means of egress doors for the clinical need of patients at the patient pavilions. Therefore, all pavilion building egress doors are not unlocked.

C. The written plan contains reference to Life Safety Code requirements which may not be applicable to this facility based upon building configuration and characteristics. References to multiple floor levels, exit stairs and smoke barriers are not applicable for the one story, patient pavilion buildings which have no smoke barrier compartmentalization due to their 28 bed capacity.

Based on observation during the survey walk-through, and document review, the facility's written plan for the protection of patients is not completely accurate. These deficiencies could affect any patients, staff, or visitors in the building because the failure to identify key life safety components could result in the failure to protect them properly.

Findings include:

On August 17, 2016 at 11:00am while in the company of the CBE & SO during review of the facility's written fire plan it was observed that the plan did not accurately reflect all conditions present at this facility.

Examples include:

A. The written plan indicates under "Objectives" paragraph 5, and in numerous other locations within the written plan regarding fire drills, that "at least 50% are unannounced". All drills are to be "unannounced" to comply with the requirements that drills be conducted at unexpected times under varying conditions to comply with 19.7.1.2.

B. The written plan indicates under LS.02.01.20 that egress doors are unlocked. This facility uses the provisions of 19.2.2.2.2 Exception No.2 to permit locking of means of egress doors for the clinical need of patients. Therefore, all egress doors are not unlocked.

C. The written plan contains reference to Life Safety Code requirements which may not be applicable to this facility based upon building configuration and characteristics. References to multiple floor levels, exit stairs and smoke barriers are not applicable for the one story, patient pavilion buildings which have no smoke barrier compartmentalization due to their 28 bed capacity.

Based on direct observation during the survey walk-through, the facility failed to provide a fire alarm system with approved components, devices or equipment installed in accordance with code. This deficiency could affect patients, staff and visitors if there was an inadvertant disconnection of the fire alarm system's power supply to prevent the fire alarm from functioning.

Findings include:

On August 16, 2016 at 2:35 pm while in the company of a BE & E, the surveyors observed, at the basement mechanical room at Panel EM-3, that the circuit serving the fire alarm panel was not provided with a mechanical lock-on device as required by NFPA 72 1999 1-5.2.5.2.

Based on direct observation during the survey walk-through, the facility failed to provide a fire alarm system with approved components, devices or equipment installed in accordance with code. This deficiency could affect patients, staff and visitors if there was an inadvertant disconnection of the fire alarm system's power supply to prevent the fire alarm from functioning.

Findings include:

On August 16, 2016 at 3:05 pm while in the company of a BE & E, the surveyors observed at the basement mechanical room at Panel EM-5 that the circuit serving the fire alarm panel was not provided with red markings and was not provided with a mechanical lock-on device as required by NFPA 72 1999 1-5.2.5.2.

Based on direct observation during the survey walk-through, the facility failed to provide a fire alarm system with approved components, devices or equipment installed in accordance with the code. This deficiency could affect patients, staff and visitors if there was an inadvertant disconnection of the fire alarm system's power supply to prevent the fire alarm from functioning.

Findings include:

On August 16, 2016 at 1:55 pm while in the company of a BE & E, the surveyors observed, at the basement mechanical room at Panel EM-1, the circuit serving the fire alarm panel was not provided with a mechanical lock-on device as required by NFPA 72 1999 1-5.2.5.2. The panel directory marked "fire alarm" was marked through but the circuit was turned on.

Based on observation the facility failed to provide adequate sprinkler protection in all areas of the buildings.These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

A. On August 16, 2016 at 1:46pm while accompanied by CBE, the surveyors observed sprinkler heads located less than 6 feet apart. This condition does not comply with NFPA 13 1999 5-6.3.4.

Location observed: laundry room

Based on observation the facility failed to provide adequate sprinkler protection in all areas of the buildings. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

A. On August 16, 2016 at 2:46pm while accompanied by CBE the surveyors observed sprinkler heads located less than 6 feet apart. This condition does not comply with NFPA 13 1999 5-6.3.4.

Location observed: laundry room

Based on observation the facility failed to provide adequate sprinkler protection in all areas of the buildings.. This condition could affect sprinkler coverage and the protection of patients and staff during a fire and smoke event. not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

A. On August 16, 2016 at 1:46pm while accompanied by CBE the surveyors observed sprinkler heads located less than 6 feet apart. This condition does not comply with NFPA 13 1999 5-6.3.4.

Location observed: laundry room

Based on observation the facility failed to provide adequate sprinkler protection in all areas of the buildings.. This condition could affect sprinkler coverage and the protection of patients and staff during a fire and smoke event. not all portions of the facility's automatic sprinkler system are installed and maintained in accordance with NFPA 13 1999. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

A. On August 17, 2016 at 10:46am while accompanied by CBE the surveyors observed sprinkler heads located less than 6 feet apart. This condition does not comply with NFPA 13 1999 5-6.3.4.

Location observed: laundry room

Based on observation, the facility failed to maintain a proper emergency power system. If the generator catches fire, emergency personnel would be at greater risk without a remote shut of of the generator.

Findings Include:

On 8/16/16 at 2:05 PM, while accompanied by the BE and E, the surveyor observed the emergency generators are not equipped with a remote stop switch in accordance with the 1999 Edition of NFPA-110, Section 3-5.5.6.

Based on observation, the facility failed to maintain a proper emergency power system. If the generator fails to operate upon the loss of normal power, this could affect all occupants of the building.

Findings Include:

On 8/17/16 at 11:00 AM, while accompanied by the BE and E, the surveyor observed the emergency generator annunciator is not located at a 24 hour staffed location in accordance with the 1999 addition of NFPA-110, Section 3-5.6.1.

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, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/16/16 at 1:00 PM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/16/16 at 1:20 PM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/16/16 at 1:55 PM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/16/16 at 2:25 PM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/16/16 at 2:50 PM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/17/16 at 8:30 AM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/17/16 at 9:05 AM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/17/16 at 9:35 AM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 8/17/16 at 9:55 AM, while accompanied by the BE and the E, the surveyor observed the emergency power was not configured as a type 1 system. A large 750 KW generator served as a secondary source for the entire facility upon loss of the utility power source, and a smaller 200 KW generator provided life safety branch power for the facility. There was no separate critical or equipment branch of emergency power. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Based upon survey walk-through direct observation, electrical systems are not installed in accordance with requirements in all areas. Failure to provide proper electrical installations can result in electrical shock hazards to occupants.

Findings include:

A. On August 16, 2016 at 3:10 pm while in the company of the BE & E it was observed that electrical duplex outlets adjacent the sink in the Laundry and Janitor rooms could not be confirmed to be GFCI protected to comply with NFPA 70-1999, 210-8(b). Although GFCI breakers were observed in the building electrical panel, the directory did not clearly identify these outlets as GFCI.

B. On August 16, 2016 at 3:15pm while in the company of the BE & E it was observed that building electrical panel "B" lacked an accurate or complete panel directory to identify all circuits to comply with NFPA 70-1999, 384-13. Two 2-pole breakers were turned ON but their use could not be determined by observation or staff interview.