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Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 18.3.6.1. These deficiencies could affect all 50 beds in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result in delayed activation of the fire alarm system and smoke compromising the facility's exit access corridors.

Findings include:

A. On the afternoon of May 4, 2011, the 1st floor Main Lobby waiting area which is open to the corridor was observed to lack a smoke detection required by 18.3.6.1 Exception 2, subpart (b).


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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 18.3.6.3. This deficiency could affect all patients in the 1st floor ICU facility, as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.

Findings include:

A. On the afternoon of May 4, 2011, two pairs of corridor doors to the 1st floor ICU suite were observed to have a 1/2" gap between the meeting edges of the doors in lieu of the 1/8" accepted as meeting the requirements for being resistant to the passage of smoke required by 18.3.6.3.1.

B. On the afternoon of May 4, 2011, the pair of corridor doors to the 1st floor Dining room were observed to have a 1/2" gap between the meeting edges of the doors in lieu of the 1/8" accepted as meeting the requirements for being resistant to the passage of smoke required by 18.3.6.3.1.

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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 18.3.2.1. These deficiencies could affect all patients on the 1st and 2nd floors of the facility, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:

A. Doors to hazardous rooms were observed that do not carry a minimum 3/4 hour fire resistance rating and/or be provided with a closer as required by 18.3.2.1. and 8.2.3.2.3.1(2). Locations observed include:
1. On the morning of May 4, 2011 the 2nd floor room labeled as the Multipurpose room was observed to be used as a storage room for beds and/or equipment. The storage function of the room constitutes a hazardous area.

2. On the afternoon of May 4, 2011 the 1st floor Maintenance area was observed to be used as a storage location for materials and supplies and was indicated by staff to be utilized for repair functions. The storage and repair shop functions constitute a hazardous area.


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Based on random observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 18.2.1 and Chapter 7. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. On the afternoon of May 4, 2011, both sets of the horizontal sliding vestibule doors at the Main Entry and the Ambulance entry were observed to be provided with dead bolt locks which prevent the emergency swing operation of the doors to allow egress when the power operators are disengaged after hours. An obvious method of operation of the doors was not provided to comply with 7.2.1.5.4.


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Based on random observation during the survey walk-through, exit signs were not fully visible to designate the path of egress in all cases in accordance with 18.2.10.1. and 7.10. These deficiencies could affect all patients on the 3rd floor of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. Egress paths were observed that are not identified by fully visible exit signs as required by 7.10.1.7. Locations observed include:

1. On the morning of May 4, 2011 full view of the exit signs on the 3rd floor were observed to be obstructed by ceiling soffits and/or placement of the signage.
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Based on document review, the written Fire and Emergency Policy & Procedure Plan is not written to address the specific conditions present at this facility. This deficiency could affect all patients in the facility as well as any staff and visitors present, because the document may reference equipment or procedures which do not exist or do not apply to this facility resulting in confusion by the reference to non-existant equipment or extraneous information.

Findings include:

1. Documents reference a "Medical Center" although the policies are titled for the "Hospital".

2. Documents reference equipment such as fire pumps, water storage tanks, sliding/rolling shutters, etc. as not applicable to this facility because they do not exist at this facility. Reference to such equipment is not warranted.


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Based on document review, fire drill documentation is not completed in accordance with 18.7.1.2. This deficiency could affect all 50 patient beds in the facility as well as any staff and visitors present, because the failure to document acceptable response to the facility's fire plan may result in deficient response actions which remain unrecognized and uncorrected.

Findings include:

A. Based on document review, fire drills documentation response checklists:

1. Are not always filled out completely.

2. Do not provide the name of the individual filling out the forms.

3. Do not tabulate the score values used to determine an acceptable response.

B. Based upon document review, fire drills are not documented to be conducted at least once per shift per quarter year in accordance 18.7.1.2. 1st shifts is 7 am to 7 pm and 2nd shift is 7 pm to 7 am. The following drills were noted during the last year:

1. At 7 am on 10/29/10 (2nd shift)
2. At 11:30 am on 10/18/10 (1st shift)
3. At 7:45 pm on 6/13/10 (2nd shift)
4. At 10:15 am on 6/8/10 (1st shift)
5. At 7:50 pm on 3/30/10 (2nd shift)
6. At 5:40 am on 3/11/10 (2nd shift)
7. At 5:45 am on 3/10/10 (2nd shift)
8. At 9:10 am on 3/9/10 (1st shift)

The above information indicates that drills were not conducted during the 3rd quarter of 2010 and the 1st quarter of 2011.


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Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 18.3.4. This deficiency could affect all 50 patient beds in the facility, as well as any staff and visitors present, as well as any staff and visitors present, because the improper installatiion of smoke detection devices could result in delayed activation of the fire alarm system and smoke compromising the facility's exit access corridors.

Findings include:

A. On the afternoon of May 4, 2011 smoke detection devices in the Main Lobby corridor were observed to be mounted on a lower panelized ceiling system rather than at the main ceiling of the space to comply with NFPA 72-1999, 2-3.4.3.1.


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Based on random observation during the survey walk-through, the medical gas storage tank arrangements were observed to not be in conformance with NFPA 99-1999, 8-3.1.11.2. This condition could affect all patients on the 2nd and 3rd floors of the facility, as well as any staff and visitors present, by exposing combustible materials in close proximty to tank storage to possible oxygen rich environment which could result in ignition of fire.

Findings include:

A. On the morning of May 4, 2011, the medical gas tank storage located in the 2nd and 3rd floor Supply Storage rooms were observed not to be separated from combustible materials on shelving by a minimum distance of 5' to comply with NFPA 99-1999, 8-3.1.11.2(c)2. Although line markings on the floor were provided, it was not clearly defined what the markings meant. If tanks could be stored anywhere within the line, the required separation from combustibles on shelving could not be met.



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Based on random observation during the survey walk-through, the piped medical gas system does not comply with requirements of NFPA 99-1999, 4-3.1.2.9(b). This condition could affect all 50 patient beds of the facility, as well as any staff and visitors present, by exposing occupants to an oxygen rich environment in the event of a breech in the piping system. The potential for ignition of fire is greatly increased in an oxygen rich environment.

Findings include:

A. On the morning of May 4, 2011, the copper medical gas piping system observed in the 1st floor Mechanical room and in the corridor near the 1st floor ICU was not supported by copper materials in contact with the piping. Although copper anchor brackets were utilized, the piping was supported from painted steel trapeze hangers and no separation of the dissimilar metals was provided to prevent electrolytic corrosion. This condition appeared to be typical through the building.



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Based on random 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.