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Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that five exits from the building had a continuous hard or paved surface from the exit discharge to the common way. This could affect all individuals using these exits during a fire emergency.

Findings include:

Tour was conducted with Staff H, Staff I, Staff J, Staff K, and Staff L on 01/18/11 from from 2:15 PM until 4:00 PM. During the tour it was observed that exits lacked a continuous hard or paved surface from the exit discharge to the common way as follows:

One of two exits out of the gym had a concrete pad outside the exit door but lacked a continuous hard or paved surface from the concrete pad to the common way. An individual using this exit would have to travel approximately ten feet across grass to the common way.

Exit Y10162 had a concrete pad outside the exit door but lacked a continuous hard or paved surface to the common way. An individual using this exit would have to travel approximately eight feet across grass to the common way.

The double exit doors to the playground had a concrete pad outside the doors but lacked a continuous hard or paved surface to the common way. An individual using this exit would have to travel approximately 60 feet to the common way.

Exit Y10058 had a concrete pad outside the exit door but lacked a continuous hard or paved surface to the common way. An individual using this exit would have to travel approximately 20 feet across grass to the common way.

Exit Y10050B had a concrete pad outside the exit door but lacked a continuous hard or paved surface to the common way. An individual using this exit would have to travel approximately 100 feet across grass to the common way.

These findings were confirmed by Staff H and Staff I during the tour.

Based on observations and staff interview, the facility failed to ensure two exit access doors in the operating room suite were arranged so that the exits were readily accessible at all times in accordance with the code at 19.2.1 and 7.2.1.5.4. The facility had a total census of 110 and a census of 80 patients during this survey.

Findings include:

A tour was conducted of the operating room suite on 01/19/11 between 2:50 PM and 3:10 PM with Staff N and O. Operating rooms #3 and #4 were observed with two exit access doors with a deadbolt lock on each of these doors. The deadbolts were located 9 and 1/2 inches over the door handles. In order to open the doors, a two step release operation had to be used. This finding was verified with Staff N and O at the time of tour.

The code requires exit access doors to release with an obvious method of operation that is readily operated under all lighting conditions and with not more than one releasing operation.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that two exits from the building had exterior light fixtures to illuminate the exit discharge. This
could affect all individuals who might need to use these exits in case of fire emergency.

Findings include:

Tour was conducted with Staff H, Staff I, Staff J, Staff K, and Staff L on 01/18/11 from 2:15 PM until 4:00 PM. During the tour it was observed that exit doors Y10058 and Y10050B lacked any exterior lighting. These findings were confirmed by Staff H and Staff I during the tour.

Based on observations and staff interviews, the facility failed to ensure 7 exit discharges and the exit discharge pathway leading from 3 exit discharges were arranged so that failure of any single lighting fixture (bulb) would not leave the area in darkness in accordance with the code at 19.2.8 and 7.8. This affected all patients, staff, and visitors. The total was 110 and the census was 80 patients.

Findings include:

A tour was conducted on 01/18/11 between 1:50 PM and 3:30 PM, and on 01/19/11 from 8:50 AM to 4:43 PM, with Staff N and O. The exits were observed with either one single light fixture or lacked any type of lighting. This finding was verified with Staff N on tour. The affected exits are as follows:

A) The exit from the outpatient rehab area,
B) Three exits leading into the courtyard where the gazebo is located (from the stairs, from the pharmacy, and the exit near the vending machines leading to this courtyard. The courtyard was observed with approximately 125 feet of sidewalk leading to the common way, which lacked discharge lighting),
C) The exit outside the cafeteria serving area and dining room,
D) The exit outside Dining room #2,
E) And the stairwell exit door located by Dining room #2.

During tour, Staff N and O verified the lack of adequate lighting along the exit discharge pathway and at the exit discharges.

Based on observations and staff interviews, the facility failed to ensure smoke detectors were located at least 36 inches from air supply/return vents. This involved smoke detectors in the facility on all three floors. The facility had a total capacity of 110 and a census of 80 patients during this survey. The NFPA 72 Code states that smoke detectors are not be located in a direct airflow or closer than 3 feet from an air supply diffuser or return air opening.

Findings include:

A tour was conducted on 01/18/11 between 1:50 PM and 3:30 PM, and on 01/19/11 from 8:50 AM to 4:43 PM, with Staff N and O. Smoke detectors were observed located within 36 inches of air supply diffusers and air return openings as followed:

A) Patient rooms 1024, 1023, 1022, 1021, 1019, 1018, 1017, 1015, 1014, 1008, 1009, 1011, 1006, 1005, 1004, 1003, 1002, 1001,

B) Cardiopulmonary (CP) area, 2 by door S1N0213, between S1N0187, by the elevator lobby, CP work area S1SE0003, the CP lab, EKG room, Echo Room, and EEG room,

C) In patient rehab kitchen, outside occupational therapy (OT) by S1SEO50A door, in the elevator lobby by medical records, and by the East guest elevator.

D) In the medical records physicians' dictation room,

E) In the Resident sleeping area in one sleeping room,

F) In the CT scan room, and

G) Two in the emergency department

On the Second Floor:
By room 2017 and in rooms 1015, 2011, 2012, 2018, 2019, 2020, 2021, 2022, 2023, 2024, 2116 Ante room, room 2109, and 2108.

On the Ground Floor:
In the lab, by the dirty dock, 2 in the pharmacy, and one by door SGN0121, by the Staff elevators, and to the mechanical hallway by the volunteer office.

These smoke detector locations were verified with Staff N and O during tour.

Based on observations and staff interviews, the facility failed to ensure one medical gas storage room was protected in accordance with NFPA 99, 4.3.1.1.2. This could affect all patients, staff, and visitors in the facility. The total capacity is 110 and the census was 80 patients.

Findings include:

A tour was conducted on 01/19/11 at 2:15 PM with Staff N and O. The ground floor was observed with a medical gas storage room, labeled SGW00S2, which contained compressed medical gases. The electric wall switch (for the lights) was observed less than 5 feet above the floor level (approximately 4 feet). This was verified by Staff N and O at the time of tour. The code requires the electrical switches to be at least 5 feet above the floor level.

All means of egress shall be in accordance with Chapter 7 and this chapter. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. Ch. 38.2.1.1., Ch.7.10.2

This requirement is NOT MET as evidenced by:

Based on observations made during tour and staff confirmation, it was determined that the facility failed to ensure that a directional exit sign was placed to show the direction of exit travel along one of two paths of egress from the sleep center.

Findings include:

Tour was conducted of the sleep center, on the lower level of the Physicians' Office Building, with Staff H and Staff I on 01/19/11 beginning at 10:45 AM. Upon exiting the sleep center and following the exit sign that indicated a path of egress through a doorway to the west of the center, the path of egress continued beyond the door into a stairwell. Within the stairwell there was a door directly ahead which appeared to be the direction of egress. However, the actual path of egress required a turn to the right to follow up the stairs to the ground level of the building, where the exit to the outside was located. Staff N confirmed upon observing the exit pathway on 01/19/11 at 3:15 PM that the direction of exit travel was not apparent.

Based on staff interviews and review of the fire watch plan, the facility failed to have a policy that included the person/persons responsible for performing the fire watch and failed to state the frequency of the actual fire watch in the event the required automatic sprinkler system is out of service for more than 4 hours in a 24 hour period. The facility had a total census of 110 and a census of 80 patients during this survey.

Findings include:

On 01/21/10 at 10:20 AM, the fire watch plan was reviewed and discussed with Staff N. The fire watch plan lacked the person responsible for performing the fire watch and the frequency the watch should be conducted. This was verified with Staff N at the time the plan was reviewed.

Based on staff interviews, and review of the fire watch plan, the facility failed to have a policy that included the person/persons responsible for performing the fire watch, and failed to state the frequency of the actual fire watch in the event the required automatic sprinkler system is out of service for more than 4 hours in a 24 hour period. The facility had a total census of 110 and a census of 80 patients during this survey.

Findings include:

On 01/21/10 at 10:20 AM, the fire watch plan was reviewed and discussed with Staff N. The fire watch plan lacked the person responsible for performing the fire watch and the frequency the watch should be conducted. This finding was verified with Staff N at the time the plan was reviewed.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that five exits from the building had a continuous hard or paved surface from the exit discharge to the common way. This could affect all individuals using these exits during a fire emergency.

Findings include:

Tour was conducted with Staff H, Staff I, Staff J, Staff K, and Staff L on 01/18/11 from from 2:15 PM until 4:00 PM. During the tour it was observed that exits lacked a continuous hard or paved surface from the exit discharge to the common way as follows:

One of two exits out of the gym had a concrete pad outside the exit door but lacked a continuous hard or paved surface from the concrete pad to the common way. An individual using this exit would have to travel approximately ten feet across grass to the common way.

Exit Y10162 had a concrete pad outside the exit door but lacked a continuous hard or paved surface to the common way. An individual using this exit would have to travel approximately eight feet across grass to the common way.

The double exit doors to the playground had a concrete pad outside the doors but lacked a continuous hard or paved surface to the common way. An individual using this exit would have to travel approximately 60 feet to the common way.

Exit Y10058 had a concrete pad outside the exit door but lacked a continuous hard or paved surface to the common way. An individual using this exit would have to travel approximately 20 feet across grass to the common way.

Exit Y10050B had a concrete pad outside the exit door but lacked a continuous hard or paved surface to the common way. An individual using this exit would have to travel approximately 100 feet across grass to the common way.

These findings were confirmed by Staff H and Staff I during the tour.

Based on observations and staff interview, the facility failed to ensure two exit access doors in the operating room suite were arranged so that the exits were readily accessible at all times in accordance with the code at 19.2.1 and 7.2.1.5.4. The facility had a total census of 110 and a census of 80 patients during this survey.

Findings include:

A tour was conducted of the operating room suite on 01/19/11 between 2:50 PM and 3:10 PM with Staff N and O. Operating rooms #3 and #4 were observed with two exit access doors with a deadbolt lock on each of these doors. The deadbolts were located 9 and 1/2 inches over the door handles. In order to open the doors, a two step release operation had to be used. This finding was verified with Staff N and O at the time of tour.

The code requires exit access doors to release with an obvious method of operation that is readily operated under all lighting conditions and with not more than one releasing operation.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that two exits from the building had exterior light fixtures to illuminate the exit discharge. This
could affect all individuals who might need to use these exits in case of fire emergency.

Findings include:

Tour was conducted with Staff H, Staff I, Staff J, Staff K, and Staff L on 01/18/11 from 2:15 PM until 4:00 PM. During the tour it was observed that exit doors Y10058 and Y10050B lacked any exterior lighting. These findings were confirmed by Staff H and Staff I during the tour.

Based on observations and staff interviews, the facility failed to ensure 7 exit discharges and the exit discharge pathway leading from 3 exit discharges were arranged so that failure of any single lighting fixture (bulb) would not leave the area in darkness in accordance with the code at 19.2.8 and 7.8. This affected all patients, staff, and visitors. The total was 110 and the census was 80 patients.

Findings include:

A tour was conducted on 01/18/11 between 1:50 PM and 3:30 PM, and on 01/19/11 from 8:50 AM to 4:43 PM, with Staff N and O. The exits were observed with either one single light fixture or lacked any type of lighting. This finding was verified with Staff N on tour. The affected exits are as follows:

A) The exit from the outpatient rehab area,
B) Three exits leading into the courtyard where the gazebo is located (from the stairs, from the pharmacy, and the exit near the vending machines leading to this courtyard. The courtyard was observed with approximately 125 feet of sidewalk leading to the common way, which lacked discharge lighting),
C) The exit outside the cafeteria serving area and dining room,
D) The exit outside Dining room #2,
E) And the stairwell exit door located by Dining room #2.

During tour, Staff N and O verified the lack of adequate lighting along the exit discharge pathway and at the exit discharges.

Based on observations and staff interviews, the facility failed to ensure smoke detectors were located at least 36 inches from air supply/return vents. This involved smoke detectors in the facility on all three floors. The facility had a total capacity of 110 and a census of 80 patients during this survey. The NFPA 72 Code states that smoke detectors are not be located in a direct airflow or closer than 3 feet from an air supply diffuser or return air opening.

Findings include:

A tour was conducted on 01/18/11 between 1:50 PM and 3:30 PM, and on 01/19/11 from 8:50 AM to 4:43 PM, with Staff N and O. Smoke detectors were observed located within 36 inches of air supply diffusers and air return openings as followed:

A) Patient rooms 1024, 1023, 1022, 1021, 1019, 1018, 1017, 1015, 1014, 1008, 1009, 1011, 1006, 1005, 1004, 1003, 1002, 1001,

B) Cardiopulmonary (CP) area, 2 by door S1N0213, between S1N0187, by the elevator lobby, CP work area S1SE0003, the CP lab, EKG room, Echo Room, and EEG room,

C) In patient rehab kitchen, outside occupational therapy (OT) by S1SEO50A door, in the elevator lobby by medical records, and by the East guest elevator.

D) In the medical records physicians' dictation room,

E) In the Resident sleeping area in one sleeping room,

F) In the CT scan room, and

G) Two in the emergency department

On the Second Floor:
By room 2017 and in rooms 1015, 2011, 2012, 2018, 2019, 2020, 2021, 2022, 2023, 2024, 2116 Ante room, room 2109, and 2108.

On the Ground Floor:
In the lab, by the dirty dock, 2 in the pharmacy, and one by door SGN0121, by the Staff elevators, and to the mechanical hallway by the volunteer office.

These smoke detector locations were verified with Staff N and O during tour.

Based on observations and staff interviews, the facility failed to ensure one medical gas storage room was protected in accordance with NFPA 99, 4.3.1.1.2. This could affect all patients, staff, and visitors in the facility. The total capacity is 110 and the census was 80 patients.

Findings include:

A tour was conducted on 01/19/11 at 2:15 PM with Staff N and O. The ground floor was observed with a medical gas storage room, labeled SGW00S2, which contained compressed medical gases. The electric wall switch (for the lights) was observed less than 5 feet above the floor level (approximately 4 feet). This was verified by Staff N and O at the time of tour. The code requires the electrical switches to be at least 5 feet above the floor level.

All means of egress shall be in accordance with Chapter 7 and this chapter. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. Ch. 38.2.1.1., Ch.7.10.2

This requirement is NOT MET as evidenced by:

Based on observations made during tour and staff confirmation, it was determined that the facility failed to ensure that a directional exit sign was placed to show the direction of exit travel along one of two paths of egress from the sleep center.

Findings include:

Tour was conducted of the sleep center, on the lower level of the Physicians' Office Building, with Staff H and Staff I on 01/19/11 beginning at 10:45 AM. Upon exiting the sleep center and following the exit sign that indicated a path of egress through a doorway to the west of the center, the path of egress continued beyond the door into a stairwell. Within the stairwell there was a door directly ahead which appeared to be the direction of egress. However, the actual path of egress required a turn to the right to follow up the stairs to the ground level of the building, where the exit to the outside was located. Staff N confirmed upon observing the exit pathway on 01/19/11 at 3:15 PM that the direction of exit travel was not apparent.

Based on staff interviews and review of the fire watch plan, the facility failed to have a policy that included the person/persons responsible for performing the fire watch and failed to state the frequency of the actual fire watch in the event the required automatic sprinkler system is out of service for more than 4 hours in a 24 hour period. The facility had a total census of 110 and a census of 80 patients during this survey.

Findings include:

On 01/21/10 at 10:20 AM, the fire watch plan was reviewed and discussed with Staff N. The fire watch plan lacked the person responsible for performing the fire watch and the frequency the watch should be conducted. This was verified with Staff N at the time the plan was reviewed.

Based on staff interviews, and review of the fire watch plan, the facility failed to have a policy that included the person/persons responsible for performing the fire watch, and failed to state the frequency of the actual fire watch in the event the required automatic sprinkler system is out of service for more than 4 hours in a 24 hour period. The facility had a total census of 110 and a census of 80 patients during this survey.

Findings include:

On 01/21/10 at 10:20 AM, the fire watch plan was reviewed and discussed with Staff N. The fire watch plan lacked the person responsible for performing the fire watch and the frequency the watch should be conducted. This finding was verified with Staff N at the time the plan was reviewed.

Based on staff interviews and review of the fire watch plan, the facility failed to have a policy that included the person/persons responsible for performing the fire watch and failed to state the frequency of the actual fire watch in the event the fire alarm system is out of service for more than 4 hours in a 24 hour period. The facility had a total census of 110 and a census of 80 patients during this survey.

Findings include:

On 01/21/10 at 10:20 AM, the fire watch plan was reviewed and discussed with Staff N. The fire watch plan lacked the person responsible for performing the fire watch and the frequency the watch should be conducted. This was verified with Staff N at the time the plan was reviewed.