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Based on an observation, the facility failed to provide a proper 2-hour fire barrier. This deficient practice could patients, staff and visitors if a fire was allowed to spread into the facility from the adjacent building.

Findings include:

On 07/28/15 at 2:08 PM, while accompanied by facility representatives it was determined the first floor, 2-hour barrier located above the ceiling at the double doors in corridor E151 contained a 3-inch hole through the wall that was not firestopped. This does not comply with NFPA 101, section 8.2.2.2.

Based on an observation and an interview, the facility failed to provide exit access that is readily accessible to a public-way at all times. This deficient practice could affect patients, staff and visitors if the egress doors and exit paths prevented staff and residents from exiting the area in a timely manner during an emergency.

A. On 07/28/15 at 9:50 AM, while accompanied by facility representatives it was determined the first floor exit corridor west, contained double doors for the IT-closet. The inactive door leaf contain manual flush bolts. This is not per NFPA 101, Section 19.3.6.3.2.

B. On 07/28/15 at 11:34 AM, while accompanied by facility representatives it was determined the third floor contained double doors at ICU rooms 301 and 302. The inactive door leaf contains manual flush bolts. This is not per NFPA 101, Section 19.3.6.3.2.

Based on an observation, the facility failed to install all required initiating devices to provide a "complete fire alarm system" to monitor vital equipment continuously this deficient practice could affect patients, staff and visitors if the fire alarm system failed to operate properly during a fire event.

Findings include:

On 07/28/15 at 1:53 PM, while accompanied by facility representatives, during the facility fire alarm activation it was determined the third floor, Intensive Care Unit contained 3 fire alarm strobes that were out of sequence and do not comply with NFPA 72, 4-4.4.2.3.

Based on fire alarm system document review and interview the facility failed to maintain and inspect the fire alarm system for deficiencies. This deficient practice could affect patients, staff and visitors if a fire were to occur and the fire alarm system failed to detect a problem.

Findings include:

On 07/27/15 at 4:00 PM, during document review and interview with facility staff it was determined the fire alarm smoke detector sensitivity report dated 05/07/2015 identified 32 smoke detectors that failed during testing. An interview with facility staff determined the failed detectors have not been replaced. A proper functioning fire alarm system is required per NFPA 72, section 7-3.2.1.

Based on quarterly and 5-year sprinkler documentation reviews and interview, the facility failed to provide complete required information on multi-year tests of the sprinkler system. This deficient practice could affect patients, staff and visitors if the sprinkler system failed to operate properly due to improper maintenance.

Findings include:

On 07/28/15 at 9:00 AM, during document review and facility tour it was determined the anti-freeze loop installed for the exterior sprinkler system contained one system gauge that was dated 2008. Gauges are to be recalibrated or replaced every 5 years. This does not comply with NFPA 25, section 9-2.8.2.

Based on observations and staff interviews during the survey walk-through, July 27-28, 2015, and based on document review, and staff interview, the surveyors find the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

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 an observation, the facility failed to provide a proper 2-hour fire barrier. This deficient practice could patients, staff and visitors if a fire was allowed to spread into the facility from the adjacent building.

Findings include:

On 07/28/15 at 2:08 PM, while accompanied by facility representatives it was determined the first floor, 2-hour barrier located above the ceiling at the double doors in corridor E151 contained a 3-inch hole through the wall that was not firestopped. This does not comply with NFPA 101, section 8.2.2.2.

Based on an observation and an interview, the facility failed to provide exit access that is readily accessible to a public-way at all times. This deficient practice could affect patients, staff and visitors if the egress doors and exit paths prevented staff and residents from exiting the area in a timely manner during an emergency.

A. On 07/28/15 at 9:50 AM, while accompanied by facility representatives it was determined the first floor exit corridor west, contained double doors for the IT-closet. The inactive door leaf contain manual flush bolts. This is not per NFPA 101, Section 19.3.6.3.2.

B. On 07/28/15 at 11:34 AM, while accompanied by facility representatives it was determined the third floor contained double doors at ICU rooms 301 and 302. The inactive door leaf contains manual flush bolts. This is not per NFPA 101, Section 19.3.6.3.2.

Based on an observation, the facility failed to install all required initiating devices to provide a "complete fire alarm system" to monitor vital equipment continuously this deficient practice could affect patients, staff and visitors if the fire alarm system failed to operate properly during a fire event.

Findings include:

On 07/28/15 at 1:53 PM, while accompanied by facility representatives, during the facility fire alarm activation it was determined the third floor, Intensive Care Unit contained 3 fire alarm strobes that were out of sequence and do not comply with NFPA 72, 4-4.4.2.3.

Based on fire alarm system document review and interview the facility failed to maintain and inspect the fire alarm system for deficiencies. This deficient practice could affect patients, staff and visitors if a fire were to occur and the fire alarm system failed to detect a problem.

Findings include:

On 07/27/15 at 4:00 PM, during document review and interview with facility staff it was determined the fire alarm smoke detector sensitivity report dated 05/07/2015 identified 32 smoke detectors that failed during testing. An interview with facility staff determined the failed detectors have not been replaced. A proper functioning fire alarm system is required per NFPA 72, section 7-3.2.1.

Based on quarterly and 5-year sprinkler documentation reviews and interview, the facility failed to provide complete required information on multi-year tests of the sprinkler system. This deficient practice could affect patients, staff and visitors if the sprinkler system failed to operate properly due to improper maintenance.

Findings include:

On 07/28/15 at 9:00 AM, during document review and facility tour it was determined the anti-freeze loop installed for the exterior sprinkler system contained one system gauge that was dated 2008. Gauges are to be recalibrated or replaced every 5 years. This does not comply with NFPA 25, section 9-2.8.2.

Based on observations and staff interviews during the survey walk-through, July 27-28, 2015, and based on document review, and staff interview, the surveyors find the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

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.