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Based on observation, record review, and interview, the facility failed to maintain a two hour barrier between two non-conforming building, to ensure the corridor walls in a non-sprinklered area extended above the ceiling to the floor above, to ensure corridor doors were in compliance with National Fire Protection Association 101, 19.3.6.3, to ensure vertical openings were enclosed with construction with a fire resistive rating of at least one hour, to maintain the rating of its smoke barriers, to ensure doors in rated barriers were rated and with self closers, to ensure its hazardous areas complied with National Fire Protection Association 101, 19.3.2.1., to maintain the protective rating of each of its exit components, to ensure its fire drills were held at unexpected times under varying conditions, to ensure its fire alarm system complied with National Fire Protection Association 72, 7-3, 1999 edition, to maintain its sprinkler system in accordance with National Fire Protection Association 25, 1999 edition, to ensure its Essential Electrical System complied with National Fire Protection Association 110, 6-4, to ensure its emergency lighting in anesthetizing locations complied with National Fire Protection Association 99, failed to ensure doors protecting corridor openings were free of penetrations, failed to comply with NFPA 99, 1999 edition, at 4-3.1.2.3 (d) for not having an intervening wall between a zone shut off valve and outlet, failed to ensure fire extinguishers complied with NFPA 10, 1999 edition and failed to ensure emergency lighting complied with NFPA 101, 7.9.3 (C231) and failed to ensure the safety of all patients on the Psychiatric Distinct Part Unit with regard to electrical cord length for the 10 beds in the unit. (C222) The facility's census was six patients.

Based on observation of the psychiatric inpatient unit and staff interview it was determined the facility failed to provide a safe environment for care. The following safety risks were observed in all ten psychiatric patient rooms and had the potential to affect all patients admitted to the unit. The current census on the distinct part psychiatric unit was 3.


Findings include:


During the tour of the psychiatric unit five new Stryker beds and five older style psychiatric hospital beds were observed. All ten patient beds had electric power cords connected to the bed and the following safety risks were identified:


1. The electrical power cords on the psychiatric inpatient beds presented a potential ligature suicide point in nine of ten patient rooms. These power cords were approximately three feet in length.


2. The ceiling Heating, Venting, and Air Conditioning (HVAC) vent in the psychiatric intensive care unit area of the unit had a wide grid that could be used as a potential ligature suicide point. This vent was covered with a thin sheet of metal with fine holes to ensure airflow during the survey.


Staff B stated in an interview on 12/02/15 at 2:35 PM the facility identified the electric power cords on the five Stryker beds as a potential hazard and notified the manufacturer to ensure the power cords were safe for the unit. The manufacturer came onsite and fixed one bed; however, the electric cords on the four new beds could not be shortened as patients were assigned to the beds. The remaining five beds currently have power cords connected to the bed.

Staff D stated in an interview on 12/03/15 at 10:05 AM the maintenance department was under the assumption the manufacturer was shortening all the electric power cords. Staff D stated the maintenance department was not notified the manufacturer was not sending a service tech and it was the facility's responsibility to shorten the power cords.

Based on observation, interview, and record review, the facility failed to ensure compliance with the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association, 101, issued January 14, 2000. This has the potential to affect all patients receiving services at the facility. The census was six patients.

Findings include:

Main Campus, existing construction

K11 Failed to maintain a two hour barrier between two non-conforming buildings

K17 Failed to ensure the corridor walls in a non-sprinklered area extended above the ceiling to the floor above

K18 Failed to ensure corridor doors were in compliance with National Fire Protection Association 101, 19.3.6.3

K20 Failed to ensure vertical openings were enclosed with construction with a fire resistive rating of at least one hour.

K25 Failed to maintain the rating of its smoke barriers

K27 Failed to ensure doors in rated barriers were rated and with self closers

K29 Failed to ensure its hazardous areas complied with National Fire Protection Association 101, 19.3.2.1.

K33 Failed to maintain the protective rating of each of its exit components

K50 Failed ensure its fire drills were held at unexpected times under varying conditions.

K52 Failed to ensure its fire alarm system complied with National Fire Protection Association 72, 7-3, 1999edition

K62 Failed to maintain its sprinkler system in accordance with National Fire Protection Association 25, 1999 edition

K144 Failed to ensure its Essential Electrical System complied with National Fire Protection Association 110, 6-4.

K145 Failed to ensure its emergency lighting in anesthetizing locations complied with National Fire Protection Association 99.

Main Campus, New Construction

K18 Failed to ensure doors protecting corridor openings were free of penetrations and those with latching hardware closed and latched

K62 Failed to ensure its sprinklers were tested in accordance with National Fire Protection Association 25, 9-3.4.2, 1999 edition.

K77 Failed to comply with National Fire Protection Association 99, 1999 edition, at 4-3.1.2.3(d), for not having an intervening wall between a zone shut off valve and the outlets it serves.

Rehab facility

K29 Failed to protect hazardous areas with self closing doors

K64 Failed to ensure fire extinguishers complied with National Fire Protection Association 10, 1999 edition.

Sleep Study Facility

K64 Failed to ensure fire extinguishers complied with National Fire Protection Association 10, 1999 edition.

K46 Failed to ensure its emergency lighting complied with National Fire Protection Association 101, 7.9.3

Based on medical record review, staff interview and policy review it was determined the facility failed to ensure patients were informed of the Important Message from Medicare regarding hospital inpatient and discharge rights upon admission. This affected three (Patient's #8, #18, #20) of twenty four medical records reviewed. The active census was 6.



Findings include:

Review of the Policy for Important Message from Medicare effective date 07/2012 states the facility is to issue the Important Message from Medicare (IM) to all fee for service Medicare and Medicare Advantage inpatients. The (IM) will be explained to the patient and or/representative and the appropriate signature indicating their understanding of their discharge rights will be obtained. The message will be delivered and explained upon admission. This is the responsibility of central registration per policy.

1. Review of the medical record for Patient #8 revealed the patient was admitted to the the facility on 09/13/15 due to a right hip fracture. The medical record lacked evidence the patient received the Important Message for Medicare. Staff A confirmed on 12/02/15 at 2:40 PM the document was unable to be located.


2. Review of the medical record for Patient #18 revealed the patient was admitted to the geropsychiatric unit on 11/17/15 with a diagnosis of anxiety. The medical record lacked evidence the patient received the Important Message for Medicare. Staff B stated the patient was involuntarily admitted through the emergency department. Staff B stated the psychiatric unit was unaware the form was not completed through registration.


3. Review of the medical record for Patient #20 revealed the patient was admitted to the facility on 08/31/15 with a diagnosis of bilateral pulmonary emboli. The medical record lacked evidence the patient received the Important Message for Medicare. Staff C confirmed this finding on 12/02/15 at 3:30 PM.