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Based on observation during the survey walk-through, not all exit access corridors are separated from use areas. These deficiencies could affect any patients, staff, or visitors in the immediate area by compromising the protection offered by the egress corridors.

Findings include:

On 08/12/15, at 9:54 AM while accompanied by the DPC, the surveyor observed exit access corridor walls in the (non-sprinklered) North Building,Second Floor Corridor, housing the Respiratory Therapy Waiting Room that do not form complete barriers to the passage of smoke, as required by 19.3.6.2.1. because:
A. Numerous wall openings were observed in the walls between the acoustic ceiling and the plaster ceiling above it.
B. Numerous holes were observed in the plaster ceiling as well.

Based on observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

A. On 08/11/15, at 2:12 PM while accompanied by the DPC, the surveyor observed a newly installed pair of doors, in the smoke barrier in the North Building Fourth Floor Behavioral Health Unit, which lacks an astragal, rabbet, or bevel required by 19.3.7.8.


B. On 08/11/15 at 2:07 PM, while accompanied by DSS, drawings were reviewed by the surveyor of the East building, 3rd floor that indicate a "smoke barrier (minimum one hour) "and a note" New double egress doors and smoke wall" .
The smoke barrier includes the "New double egress doors" across the corridor between Patient room 300 and pantry 329. Based on interview with DSS, the wall is not a required fire rated wall but is only smoke control. It was observed that the meeting edge of the doors is within 1/8" gap tolerance at the top but expands to about ½" gap at the bottom of the doors. The new double egress doors were not installed to meet the requirements of NFPA 105 " Installation of Smoke-Control Door Assemblies " (1999) 2-1.5, because they failed to include an overlapping astragal or other tested method to satisfactory seal the doors.

Based on document review and observations of hazardous areas, the facility failed to provide separation between hazardous rooms from surrounding areas. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

A. On 08/12/15, at 9:57 AM while accompanied by DSS, the surveyor reviewed the drawings of the 1990 Building, 1st floor, which indicated a 1-hour rated Clean Supply Room located in the North East corner of the Emergency Room. Clean Supply Room (Storage Room) C612 contained two unsealed conduit wall penetrations above the ceiling, on the West wall. (NFPA 101, 8.2.2.2)

B. On 08/12/15, at 9:05 AM while accompanied by DSS, the surveyor reviewed the drawings of the East Building, 1st floor, which indicated a one hour rated wall separating the kitchen from the surrounding area. The north wall of the equipment room, accessible from the kitchen office, is part of the rated kitchen separation. A 2" x 9" unsealed hole was observed in the north east corner of the wall of the equipment room. (NFPA 101, 8.2.2.2)

C. On 08/12/15, at 11:03 AM while accompanied by DSS and AMS, the surveyor reviewed the drawings of the East Building, 2nd floor, which indicate a one hour rated storage room across from the Anesthesia Office. The room contains a storage cabinet which wedges the room door open, not allowing the automatic closer to function as designed. [NFPA 101, 8.2.3.2.3(2)]

Based on observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

On 08/11/15, at 1:28 PM while accompanied by the DPC, the surveyor observed doors, on the North Building Fourth Floor (in or serving the Behavioral Health Unit), which are equipped with delayed egress locking mechanisms as prohibited by 7.2.1.6.1 because the building is not fully covered by an automatic sprinkler system.

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 08/12/15, at 9:37 AM while accompanied by the DPC, the surveyor observed an access panel, in a designated 2 hour fire rated wall between the North Building Second Floor Corridor (immediately west of the "Bridge" to the East Building) and the South Building Second Floor Laboratory which does not comply with 8.2.3.2.3.1(1) because:
A. The label indicating the access panel's fire resistance rating has been partially removed.

B. The access panel is bent out of shape and does not latch properly into the frame.

Based on observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases. 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:

On 08/11/15, at 2:21 PM while accompanied by the DPC, the surveyor observed an egress path, at the North Building Third Floor Corridor, in the area directly south of the Physical Therapy Suite, which is not provided with an exit sign which directs occupants toward the building's South Exit Stair as required by 7.10.1.1.

Based on document review and staff interview, fire drills are not held at varying times and varying conditions, and do not always include the transmission of a signal. These deficiencies could affect any patients, staff, or visitors in the building because the staff may not be properly prepared for a fire emergency, and because the building fire alarm system may not function properly under fire emergency conditions.

Findings include:

A. On 08/12/15, at 12:43 PM during the document review process and while accompanied by the DSS, the surveyor determined that fire drills are not conducted at varying times as required by 19.7.1.2. The finding was confirmed at that time by the DSS. During the calendar years 2014 and 2015, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. Second Shift:

a. March 26, 2014: 3:50 PM.

b. June 24, 2014: 3:55 PM.

c. September 25, 2014: 3:25 PM.

d. December 30, 2014: 3:15 PM.

e. March 27, 2015: 3:30 PM.

f. June 23, 2015: 3:30 PM.

2. Third Shift:
a. March 7, 2014: 4:00 AM.

b. June 7, 2014: 5:45 AM.

c. September 11, 2014: 4:00 AM.
d. December 5, 2014: 5:00 AM.

e. March 12, 2015: 4:15 AM.

f. June 18, 2015: 5:00 AM.

B. On 08/12/15, at 12:43 PM during the document review process, the DSS stated that fire drills do not include the transmission of a fire alarm signal as required by 19.7.1.2.

Based on staff interview, not all portions of the facility's automatic sprinkler system are properly installed and maintained. 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:

On 08/12/15, at 1:34 PM the CE stated the inspector's test connections, in the North Building, are not equipped with an orifice which simulates the flow of a single sprinkler head as required by NFPA 13 1999 5-15.4.2.

Based on observation made during the survey walk through , the surveyor found that the generator installation is not installed in a compliant manner. This could affect all occupants of the building if the generator does not operate during the loss of normal power.

Findings include:

On 08/12/15 at approximately 9:10 AM, the surveyor observed while accompanied by the CE, that the battery charger was connected directly at the battery terminals which is not allowed by the 1999 Edition of NFPA-110, Section 5-12.6.

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, the facility failed to install electrical wiring in accordance with the National Electrical Code. This deficient practice could affect patients, staff and visitors if an overloaded receptacle caused a fire, and any occupant of the facility could be affected if proper safety precautions are not met when electrical systems are installed.

Finding include:

A. On 8/12/15 at 9:35 AM, while accompanied by the DSS, in the East Building, 1st floor Security office the surveyor observed two surge protector power strips in use. The power strips were being utilized as extension cords in lieu of installing permanent electrical receptacles which does not comply with NFPA 70, 1999, 305-3(b) (duration of use).


17659


B. On 08/11/15 at approximately 1:15 PM, 15 the surveyor observed while accompanied by the CE, that rooms 317 through 320 in the east building were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-18 and NFPA-99, Section 3-3.2.1.2(a)1.

C. On 08/12/15 at approximately 11:05 AM, the surveyor observed while accompanied by the CE, that the operating rooms and recovery rooms were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

D. On 08/12/15 at approximately 11:00 AM, the surveyor observed while accompanied by the CE, that the operating rooms were not equipped with battery powered emergency lights to meet the requirements of NFPA-99, Section 3-3.2.1.2(a)5.e.

Based on observation during the survey walk-through, not all exit access corridors are separated from use areas. These deficiencies could affect any patients, staff, or visitors in the immediate area by compromising the protection offered by the egress corridors.

Findings include:

On 08/12/15, at 9:54 AM while accompanied by the DPC, the surveyor observed exit access corridor walls in the (non-sprinklered) North Building,Second Floor Corridor, housing the Respiratory Therapy Waiting Room that do not form complete barriers to the passage of smoke, as required by 19.3.6.2.1. because:
A. Numerous wall openings were observed in the walls between the acoustic ceiling and the plaster ceiling above it.
B. Numerous holes were observed in the plaster ceiling as well.

Based on observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

A. On 08/11/15, at 2:12 PM while accompanied by the DPC, the surveyor observed a newly installed pair of doors, in the smoke barrier in the North Building Fourth Floor Behavioral Health Unit, which lacks an astragal, rabbet, or bevel required by 19.3.7.8.


B. On 08/11/15 at 2:07 PM, while accompanied by DSS, drawings were reviewed by the surveyor of the East building, 3rd floor that indicate a "smoke barrier (minimum one hour) "and a note" New double egress doors and smoke wall" .
The smoke barrier includes the "New double egress doors" across the corridor between Patient room 300 and pantry 329. Based on interview with DSS, the wall is not a required fire rated wall but is only smoke control. It was observed that the meeting edge of the doors is within 1/8" gap tolerance at the top but expands to about ½" gap at the bottom of the doors. The new double egress doors were not installed to meet the requirements of NFPA 105 " Installation of Smoke-Control Door Assemblies " (1999) 2-1.5, because they failed to include an overlapping astragal or other tested method to satisfactory seal the doors.

Based on document review and observations of hazardous areas, the facility failed to provide separation between hazardous rooms from surrounding areas. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

A. On 08/12/15, at 9:57 AM while accompanied by DSS, the surveyor reviewed the drawings of the 1990 Building, 1st floor, which indicated a 1-hour rated Clean Supply Room located in the North East corner of the Emergency Room. Clean Supply Room (Storage Room) C612 contained two unsealed conduit wall penetrations above the ceiling, on the West wall. (NFPA 101, 8.2.2.2)

B. On 08/12/15, at 9:05 AM while accompanied by DSS, the surveyor reviewed the drawings of the East Building, 1st floor, which indicated a one hour rated wall separating the kitchen from the surrounding area. The north wall of the equipment room, accessible from the kitchen office, is part of the rated kitchen separation. A 2" x 9" unsealed hole was observed in the north east corner of the wall of the equipment room. (NFPA 101, 8.2.2.2)

C. On 08/12/15, at 11:03 AM while accompanied by DSS and AMS, the surveyor reviewed the drawings of the East Building, 2nd floor, which indicate a one hour rated storage room across from the Anesthesia Office. The room contains a storage cabinet which wedges the room door open, not allowing the automatic closer to function as designed. [NFPA 101, 8.2.3.2.3(2)]

Based on observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

On 08/11/15, at 1:28 PM while accompanied by the DPC, the surveyor observed doors, on the North Building Fourth Floor (in or serving the Behavioral Health Unit), which are equipped with delayed egress locking mechanisms as prohibited by 7.2.1.6.1 because the building is not fully covered by an automatic sprinkler system.

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 08/12/15, at 9:37 AM while accompanied by the DPC, the surveyor observed an access panel, in a designated 2 hour fire rated wall between the North Building Second Floor Corridor (immediately west of the "Bridge" to the East Building) and the South Building Second Floor Laboratory which does not comply with 8.2.3.2.3.1(1) because:
A. The label indicating the access panel's fire resistance rating has been partially removed.

B. The access panel is bent out of shape and does not latch properly into the frame.

Based on observation during the survey walk-through, exit signs did not illuminate a continuous path of egress in all cases. 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:

On 08/11/15, at 2:21 PM while accompanied by the DPC, the surveyor observed an egress path, at the North Building Third Floor Corridor, in the area directly south of the Physical Therapy Suite, which is not provided with an exit sign which directs occupants toward the building's South Exit Stair as required by 7.10.1.1.

Based on document review and staff interview, fire drills are not held at varying times and varying conditions, and do not always include the transmission of a signal. These deficiencies could affect any patients, staff, or visitors in the building because the staff may not be properly prepared for a fire emergency, and because the building fire alarm system may not function properly under fire emergency conditions.

Findings include:

A. On 08/12/15, at 12:43 PM during the document review process and while accompanied by the DSS, the surveyor determined that fire drills are not conducted at varying times as required by 19.7.1.2. The finding was confirmed at that time by the DSS. During the calendar years 2014 and 2015, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. Second Shift:

a. March 26, 2014: 3:50 PM.

b. June 24, 2014: 3:55 PM.

c. September 25, 2014: 3:25 PM.

d. December 30, 2014: 3:15 PM.

e. March 27, 2015: 3:30 PM.

f. June 23, 2015: 3:30 PM.

2. Third Shift:
a. March 7, 2014: 4:00 AM.

b. June 7, 2014: 5:45 AM.

c. September 11, 2014: 4:00 AM.
d. December 5, 2014: 5:00 AM.

e. March 12, 2015: 4:15 AM.

f. June 18, 2015: 5:00 AM.

B. On 08/12/15, at 12:43 PM during the document review process, the DSS stated that fire drills do not include the transmission of a fire alarm signal as required by 19.7.1.2.

Based on staff interview, not all portions of the facility's automatic sprinkler system are properly installed and maintained. 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:

On 08/12/15, at 1:34 PM the CE stated the inspector's test connections, in the North Building, are not equipped with an orifice which simulates the flow of a single sprinkler head as required by NFPA 13 1999 5-15.4.2.

Based on observation made during the survey walk through , the surveyor found that the generator installation is not installed in a compliant manner. This could affect all occupants of the building if the generator does not operate during the loss of normal power.

Findings include:

On 08/12/15 at approximately 9:10 AM, the surveyor observed while accompanied by the CE, that the battery charger was connected directly at the battery terminals which is not allowed by the 1999 Edition of NFPA-110, Section 5-12.6.

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, the facility failed to install electrical wiring in accordance with the National Electrical Code. This deficient practice could affect patients, staff and visitors if an overloaded receptacle caused a fire, and any occupant of the facility could be affected if proper safety precautions are not met when electrical systems are installed.

Finding include:

A. On 8/12/15 at 9:35 AM, while accompanied by the DSS, in the East Building, 1st floor Security office the surveyor observed two surge protector power strips in use. The power strips were being utilized as extension cords in lieu of installing permanent electrical receptacles which does not comply with NFPA 70, 1999, 305-3(b) (duration of use).


17659


B. On 08/11/15 at approximately 1:15 PM, 15 the surveyor observed while accompanied by the CE, that rooms 317 through 320 in the east building were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-18 and NFPA-99, Section 3-3.2.1.2(a)1.

C. On 08/12/15 at approximately 11:05 AM, the surveyor observed while accompanied by the CE, that the operating rooms and recovery rooms were not equipped with normal power receptacles to meet the requirements of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

D. On 08/12/15 at approximately 11:00 AM, the surveyor observed while accompanied by the CE, that the operating rooms were not equipped with battery powered emergency lights to meet the requirements of NFPA-99, Section 3-3.2.1.2(a)5.e.