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Based on observation during the survey walk-through, not all exit access corridors are separated from use areas as required. This deficiency could affect any patients, staff, or visitors in the building by compromising the protection offered by the egress corridors.

Findings include:

On August 24, 2016, at 9:26 AM, while accompanied by the DPO, the Surveyor observed that the former Reception Office, adjacent to the former Entry Lobby, lacks a smoke detector required by Subpart (c) of Exception 1 to 19.3.6.1 because the room is not separated from the adjacent Corridor.

Based on observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

On August 24, 2016, while accompanied by the DPO, the surveyor observed doors in smoke barrier walls, during a test of the building fire alarm system, which did not fully close as required by 19.3.7.6. Locations observed include:

A. 1:33 PM: Pair of cross-corridor doors immediately west of ICU.

B. 1:35 PM: Pair of cross-corridor doors directly north of ICU.

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 August 24, 2016, at 9:23 AM, while accompanied by the DPO, the surveyor observed that the door to Respiratory Therapy Storage Room 611 is not self-closing as required by 19.3.2.1 and 8.2.3.2.3.1(2).

B. On August 24, 2016, at 10:35 AM, while accompanied by the DPO, the surveyor observed that the door to the Kitchen Dry Storage Room was being held open by an unapproved device (a rope) as prohibited by 19.3.2.1 and 8.2.3.2.3.1(2).

Based on observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times. This deficiency could affect any staff or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

On August 24, 2016, at 10:09 AM, while accompanied by the DPO, the surveyor observed that the gate assembly for the Gift Shop can be secured against egress, as prohibited by 7.2.1.5.1, because the gate assembly can be padlocked.

Based on observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

A. On August 24, 2016, at 9:59 AM, while accompanied by the DPO, the surveyor observed that the door to the Nursing Home, which is located in a designated 2 hour fire barrier, did not close to latch as required by 8.2.3.2.3.1(1).
B. On August 24, 2016, at 10:40 AM, while accompanied by the DPO, the surveyor observed the following conditions at the fire rated door between the Kitchen Dishwashing Room and the Kitchen Area Service Corridor, as prohibited by 8.2.3.2.3.1(1)
1. The fire rating label on the door (both leafs) was observed to be painted over.

2. The active leaf of the door was observed to be held open by an unapproved device (a " WET FLOOR " sign).

Based on observation during the survey walk-through, exit signs do not illuminate a continuous path of egress in all cases. This deficiency could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

On August 24, 2016, at 10:45 AM, while accompanied by the DPO, the surveyor observed that no exit sign is provided at the northwest end of the Kitchen Area Service Corridor as required by 7.10.

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

Findings include:

On August 24, 2016, at 12:53 PM, while accompanied by the DPO and during the document review process, the surveyor determined that fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar year 2016, fire drills for the night shift (Shift 2 of 2) for the following quarters were conducted at the similar times listed:

A. February 23, 2016: 12:10 AM.

B. June 7, 2016: 12:20 AM.

C. July 22, 2016: 11:30 PM.

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed and maintained as required. This deficiency could affect any patients, staff, or visitors in the building because the fire alarm system may fail to function properly during fire emergencies.

Findings include:

On August 24, 2016, 9:15 AM, while accompanied by the DPO, the surveyor observed that Electrical Room 400, which houses the Fire Alarm Control Panel and which was observed to not be continuously occupied, lacks a smoke detector required by NFPA 72 1999 1-5.6.

Based on observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are properly installed and maintained. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

On August 24, 2016, while accompanied by the DPO, the surveyor observed rooms or spaces within designated sprinklered smoke compartments that lack sprinkler heads required by NFPA 13 1999 5-1.1.(1). Locations observed include:

A. 10:55 AM: Physical Therapy Room.

B. 10:56 AM: Corridor which serves the rooms listed in K-056 Items A, C, and D.

C. 11:00 AM: Air Compressor Room and Room immediately west of it.

D. 11:01 AM: Dietary Manager ' s Office and Outer Office which serves it.

Based observation during the survey walk-through, not all portions of the facility's commercial cooking equipment is installed and maintained as required. This deficiency could affect any staff or visitors in the area because a fire may not be contained in the Kitchen.

Findings include:

On August 24, 2016, qt 10:35 AM, while accompanied by the DPO, the surveyor observed that the Kitchen Type K fire extinguisher was observed to lack a placard, which identifies it as a secondary means of extinguishing a fire, required by NFPA 96 1998 7-2.1.1.

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:

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, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system as required. These deficiencies could affect any patients, staff, or visitors in the building because the emergency electrical system (EES) could become compromised.

Findings include:

A. On August 24, 2016, at 1:45 PM, while accompanied by the DPO, the surveyor observed that portions of the building are served by a single transfer switch, as prohibited by NFPA 70 1999 517-30(b)(4). Locations observed include:
1. The 300 Wing.

2. The Diagnostic Wing.

B. On August 24, 2016, at 1:50 PM, while accompanied by the DPO, the surveyor observed that portions of the building lack a dedicated and exclusive Life Safety Branch, as required by NFPA 70 1999 517-32(a) and NFPA 99 1999 3-4.2.2.2(b), because all Life Safety and Critical electrical loads in those portions of the building are served by the same electrical panels. Locations observed include:
1. The 300 Wing.

2. The Diagnostic Wing.

Based on observation during the survey walk-through, not all portions of the building electrical system are installed as required. These deficiencies could affect any patients being treated in the cited areas because emergency power may not be available under certain conditions, or may affect any patients, staff, or visitors in the building because the fire alarm system could become compromised.

Findings include:

A. On August 24, 2016, at 10:53 AM, while accompanied by the DPO, the surveyor observed general care patient bed locations which lack electrical receptacles served by the Critical Branch of the building's Type 1 Emergency Electrical System (EES) as required by NFPA 70 1999 517-33(a)(8)(a). Locations observed include:

1. The 300 Wing.

2. The Diagnostic Wing.

B. On August 24, 2016, at 10:55 AM, while accompanied by the DPO, the surveyor observed general care patient bed locations which lack task illumination served by the Critical Branch of the building's Type 1 EES as required by NFPA 70 1999 517-33(a)(8)(a) and NFPA 99 3-4.2.2.2(c)(8)(a). Locations observed include:

1. The 300 Wing.

2. The Diagnostic Wing.

C. On August 24, 2016, while accompanied by the DPO, the surveyor observed critical care patient bed locations which lack electrical receptacles which are served by the Normal Branch of the building's type 1 EES as required by NFPA 70 1999 517-19(a). Locations observed include:
1. 11:15 AM, 4 Bays in ICU.

2. 12:12 PM, Operating Room 12.

3. 12:20 PM, Operating Room 3.

4. 12:25 PM, Operating Room 4.

D. On August 24, 2016, while accompanied by the DPO, the surveyor observed extension cords or similar devices at patient care bed locations as prohibited by NFPA 70 1999 240-4 and NFPA 70 1999 305-5. Locations and devices observed include:

1. 12:15 PM, Operating Room 12, extension cord.

2. 12:24 PM, Operating Room 4, extension cord and multi-plex outlet extender.

Based on observation during the survey walk-through, not all exit access corridors are separated from use areas as required. This deficiency could affect any patients, staff, or visitors in the building by compromising the protection offered by the egress corridors.

Findings include:

On August 24, 2016, at 9:26 AM, while accompanied by the DPO, the Surveyor observed that the former Reception Office, adjacent to the former Entry Lobby, lacks a smoke detector required by Subpart (c) of Exception 1 to 19.3.6.1 because the room is not separated from the adjacent Corridor.

Based on observation during the survey walk-through, not all doors in smoke barrier walls are resistant to the passage of smoke. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

On August 24, 2016, while accompanied by the DPO, the surveyor observed doors in smoke barrier walls, during a test of the building fire alarm system, which did not fully close as required by 19.3.7.6. Locations observed include:

A. 1:33 PM: Pair of cross-corridor doors immediately west of ICU.

B. 1:35 PM: Pair of cross-corridor doors directly north of ICU.

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 August 24, 2016, at 9:23 AM, while accompanied by the DPO, the surveyor observed that the door to Respiratory Therapy Storage Room 611 is not self-closing as required by 19.3.2.1 and 8.2.3.2.3.1(2).

B. On August 24, 2016, at 10:35 AM, while accompanied by the DPO, the surveyor observed that the door to the Kitchen Dry Storage Room was being held open by an unapproved device (a rope) as prohibited by 19.3.2.1 and 8.2.3.2.3.1(2).

Based on observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times. This deficiency could affect any staff or visitors in the building by preventing them from reaching an exit under fire conditions.

Findings include:

On August 24, 2016, at 10:09 AM, while accompanied by the DPO, the surveyor observed that the gate assembly for the Gift Shop can be secured against egress, as prohibited by 7.2.1.5.1, because the gate assembly can be padlocked.

Based on observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass between fire compartments.

Findings include:

A. On August 24, 2016, at 9:59 AM, while accompanied by the DPO, the surveyor observed that the door to the Nursing Home, which is located in a designated 2 hour fire barrier, did not close to latch as required by 8.2.3.2.3.1(1).
B. On August 24, 2016, at 10:40 AM, while accompanied by the DPO, the surveyor observed the following conditions at the fire rated door between the Kitchen Dishwashing Room and the Kitchen Area Service Corridor, as prohibited by 8.2.3.2.3.1(1)
1. The fire rating label on the door (both leafs) was observed to be painted over.

2. The active leaf of the door was observed to be held open by an unapproved device (a " WET FLOOR " sign).

Based on observation during the survey walk-through, exit signs do not illuminate a continuous path of egress in all cases. This deficiency could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

On August 24, 2016, at 10:45 AM, while accompanied by the DPO, the surveyor observed that no exit sign is provided at the northwest end of the Kitchen Area Service Corridor as required by 7.10.

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

Findings include:

On August 24, 2016, at 12:53 PM, while accompanied by the DPO and during the document review process, the surveyor determined that fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar year 2016, fire drills for the night shift (Shift 2 of 2) for the following quarters were conducted at the similar times listed:

A. February 23, 2016: 12:10 AM.

B. June 7, 2016: 12:20 AM.

C. July 22, 2016: 11:30 PM.

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed and maintained as required. This deficiency could affect any patients, staff, or visitors in the building because the fire alarm system may fail to function properly during fire emergencies.

Findings include:

On August 24, 2016, 9:15 AM, while accompanied by the DPO, the surveyor observed that Electrical Room 400, which houses the Fire Alarm Control Panel and which was observed to not be continuously occupied, lacks a smoke detector required by NFPA 72 1999 1-5.6.

Based on observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are properly installed and maintained. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

On August 24, 2016, while accompanied by the DPO, the surveyor observed rooms or spaces within designated sprinklered smoke compartments that lack sprinkler heads required by NFPA 13 1999 5-1.1.(1). Locations observed include:

A. 10:55 AM: Physical Therapy Room.

B. 10:56 AM: Corridor which serves the rooms listed in K-056 Items A, C, and D.

C. 11:00 AM: Air Compressor Room and Room immediately west of it.

D. 11:01 AM: Dietary Manager ' s Office and Outer Office which serves it.

Based observation during the survey walk-through, not all portions of the facility's commercial cooking equipment is installed and maintained as required. This deficiency could affect any staff or visitors in the area because a fire may not be contained in the Kitchen.

Findings include:

On August 24, 2016, qt 10:35 AM, while accompanied by the DPO, the surveyor observed that the Kitchen Type K fire extinguisher was observed to lack a placard, which identifies it as a secondary means of extinguishing a fire, required by NFPA 96 1998 7-2.1.1.

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:

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, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system as required. These deficiencies could affect any patients, staff, or visitors in the building because the emergency electrical system (EES) could become compromised.

Findings include:

A. On August 24, 2016, at 1:45 PM, while accompanied by the DPO, the surveyor observed that portions of the building are served by a single transfer switch, as prohibited by NFPA 70 1999 517-30(b)(4). Locations observed include:
1. The 300 Wing.

2. The Diagnostic Wing.

B. On August 24, 2016, at 1:50 PM, while accompanied by the DPO, the surveyor observed that portions of the building lack a dedicated and exclusive Life Safety Branch, as required by NFPA 70 1999 517-32(a) and NFPA 99 1999 3-4.2.2.2(b), because all Life Safety and Critical electrical loads in those portions of the building are served by the same electrical panels. Locations observed include:
1. The 300 Wing.

2. The Diagnostic Wing.

Based on observation during the survey walk-through, not all portions of the building electrical system are installed as required. These deficiencies could affect any patients being treated in the cited areas because emergency power may not be available under certain conditions, or may affect any patients, staff, or visitors in the building because the fire alarm system could become compromised.

Findings include:

A. On August 24, 2016, at 10:53 AM, while accompanied by the DPO, the surveyor observed general care patient bed locations which lack electrical receptacles served by the Critical Branch of the building's Type 1 Emergency Electrical System (EES) as required by NFPA 70 1999 517-33(a)(8)(a). Locations observed include:

1. The 300 Wing.

2. The Diagnostic Wing.

B. On August 24, 2016, at 10:55 AM, while accompanied by the DPO, the surveyor observed general care patient bed locations which lack task illumination served by the Critical Branch of the building's Type 1 EES as required by NFPA 70 1999 517-33(a)(8)(a) and NFPA 99 3-4.2.2.2(c)(8)(a). Locations observed include:

1. The 300 Wing.

2. The Diagnostic Wing.

C. On August 24, 2016, while accompanied by the DPO, the surveyor observed critical care patient bed locations which lack electrical receptacles which are served by the Normal Branch of the building's type 1 EES as required by NFPA 70 1999 517-19(a). Locations observed include:
1. 11:15 AM, 4 Bays in ICU.

2. 12:12 PM, Operating Room 12.

3. 12:20 PM, Operating Room 3.

4. 12:25 PM, Operating Room 4.

D. On August 24, 2016, while accompanied by the DPO, the surveyor observed extension cords or similar devices at patient care bed locations as prohibited by NFPA 70 1999 240-4 and NFPA 70 1999 305-5. Locations and devices observed include:

1. 12:15 PM, Operating Room 12, extension cord.

2. 12:24 PM, Operating Room 4, extension cord and multi-plex outlet extender.