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Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. On June 29, 2015, while accompanied by the Maintenance Director, the surveyor observed hazardous areas at which doors are not positive latching as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include:

1. 1:08 PM: Soiled Utility Room for Med-Surg Unit.
2. 1:22 PM: Soiled Utility Room for Emergency Department/Radiology Department.

Based on document review and staff interview, fire drills are not held at varying times and varying conditions. These deficiencies could affect any patients, staff, or visitors in the building because the staff may not be properly prepared for a fire emergency.

Findings include:

A. At 1:56 PM on June 29, 2015, while accompanied by the Maintenance Director, the review of documents by the surveyor indicated that fire drills are not conducted at varying times as required by 19.7.1.2. This was confirmed at that time by the Maintenance Director. During the calendar years 2014 and 2015, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. AM Shift:

a. January 9, 2014: 2:15 PM.

b. April 16, 2014: 1:45 PM.

c. August 8, 2014: 1:10 PM.

d. October 13, 2014: 12:52 PM.

e. May 5, 2015: 2:30 PM.

2. Third Shift:
a. March 28, 2014: 4:00 AM.

b. July 1, 2014: 5:00 AM.

c. December 24, 2014: 4:45 PM.

d. June 25, 2015: 5:00 PM.

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:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

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

Findings include:

A. At 10:43 AM on June 29, 2015, while accompanied by the Maintenance Director, the surveyor observed that Basement Electrical Panel P3, located in the Kitchen adjacent to the convection oven, lacks a clear working space of 3'-0" in front of the panel as required by NFPA 70 1999 110-26(a).

B. At 10:17 AM on June 29, 2015, while accompanied by the Maintenance Director, the surveyor observed that Basement Electrical Panel CP, located in a Basement Electrical Room, is not provided with an accurate panel directory required by NFPA 70 1999 384-13.

C. On June 29, 2015, while accompanied by the Maintenance Director, the surveyor observed general care patient beds at which at least 1 duplex electrical receptacle is not from the Critical Branch of the building's Type 1 Essential Electrical System (EES) as required by NFPA 70 1999 517-18(a). Locations observed include:
1. 12:51 PM: Same Day Surgery Pre/Post Operative Bays, 5 thus.

2. 12:57 PM: Endoscopy Procedure Room.

3. 1:20 PM: All Patient Sleeping Rooms, 9 thus.

D. On June 29, 2015, while accompanied by the Maintenance Director, the surveyor observed critical care patient beds at which at least 1 duplex electrical receptacle is not from the Critical Branch of the building's Type 1 Essential Electrical System (EES) as required by NFPA 70 1999 517-18(a). Locations observed include:

1. 1:03 PM: Operating Room.

2. 1:13 PM: Stage I Recovery Bay.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

A. On June 29, 2015, while accompanied by the Maintenance Director, the surveyor observed hazardous areas at which doors are not positive latching as required by 19.3.2.1. and 8.2.3.2.3.1.(2). Locations observed include:

1. 1:08 PM: Soiled Utility Room for Med-Surg Unit.
2. 1:22 PM: Soiled Utility Room for Emergency Department/Radiology Department.

Based on document review and staff interview, fire drills are not held at varying times and varying conditions. These deficiencies could affect any patients, staff, or visitors in the building because the staff may not be properly prepared for a fire emergency.

Findings include:

A. At 1:56 PM on June 29, 2015, while accompanied by the Maintenance Director, the review of documents by the surveyor indicated that fire drills are not conducted at varying times as required by 19.7.1.2. This was confirmed at that time by the Maintenance Director. During the calendar years 2014 and 2015, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. AM Shift:

a. January 9, 2014: 2:15 PM.

b. April 16, 2014: 1:45 PM.

c. August 8, 2014: 1:10 PM.

d. October 13, 2014: 12:52 PM.

e. May 5, 2015: 2:30 PM.

2. Third Shift:
a. March 28, 2014: 4:00 AM.

b. July 1, 2014: 5:00 AM.

c. December 24, 2014: 4:45 PM.

d. June 25, 2015: 5:00 PM.

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:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

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

Findings include:

A. At 10:43 AM on June 29, 2015, while accompanied by the Maintenance Director, the surveyor observed that Basement Electrical Panel P3, located in the Kitchen adjacent to the convection oven, lacks a clear working space of 3'-0" in front of the panel as required by NFPA 70 1999 110-26(a).

B. At 10:17 AM on June 29, 2015, while accompanied by the Maintenance Director, the surveyor observed that Basement Electrical Panel CP, located in a Basement Electrical Room, is not provided with an accurate panel directory required by NFPA 70 1999 384-13.

C. On June 29, 2015, while accompanied by the Maintenance Director, the surveyor observed general care patient beds at which at least 1 duplex electrical receptacle is not from the Critical Branch of the building's Type 1 Essential Electrical System (EES) as required by NFPA 70 1999 517-18(a). Locations observed include:
1. 12:51 PM: Same Day Surgery Pre/Post Operative Bays, 5 thus.

2. 12:57 PM: Endoscopy Procedure Room.

3. 1:20 PM: All Patient Sleeping Rooms, 9 thus.

D. On June 29, 2015, while accompanied by the Maintenance Director, the surveyor observed critical care patient beds at which at least 1 duplex electrical receptacle is not from the Critical Branch of the building's Type 1 Essential Electrical System (EES) as required by NFPA 70 1999 517-18(a). Locations observed include:

1. 1:03 PM: Operating Room.

2. 1:13 PM: Stage I Recovery Bay.