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Based on random observation during the survey walk-through, accompanied by facility staff, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke to enter the egress corridor.

Findings include:

A. At 12:37 PM on 08/26/2014 in the corridor that serves the X-Ray Suite, a waiting area which is not constantly attended and which is open to the adjacent corridor, was observed to lack smoke detectors required by Subpart (b) of Exception 2 to 19.3.6.1.

Based on random observation during the survey walk-through, accompanied by facility staff, the facility failed to maintain automatic closing for smoke barrier doors. This deficiency could affect patients, staff, and visitors in the Hinton and Brunk units if the doors do not close properly and smoke was allowed to pass from one smoke zone to another smoke zone.
Findings include:

A. At 8:37 AM on 08/26/2014 at the staff conference room behind the Hinton unit nurses ' station, a door in the smoke barrier between the Hinton and Brunk units was observed to be not self closing as required by 19.3.7.6

Based on random observation during the survey walk-through, accompanied by facility staff, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2. These deficiencies could affect all patients, staff, and visitors within the smoke compartment of the location by allowing smoke and fire to escape from hazardous rooms into the exit access corridor.

Findings include:

A. At 9:05 AM on 08/26/2014 in the mechanical room located at the northwest corner of the building it was observed that there are unsealed penetrations through the east wall. 19.3.2.1

Based on random observation during the survey walk-through, accompanied by facility staff, the facility failed to provide a fire alarm system with approved components, devices or equipment installed according to NFPA 72. This deficiency would affect all patients, staff, and visitors if a fire would start.

Findings include:

A. At 2:10 PM on 08/25/2014 in the electrical room it was observed that the fire alarm control panel is not labeled as to the panel and circuit that serve it. NFPA 72 1999 1-5.2.5.2

Based on random observation during the survey walk-through, accompanied by facility staff, the facility failed to provide a fire alarm system with approved components, devices or equipment installed according to NFPA 72. This deficiency would affect all patients, staff, and visitors if a fire would start.

Findings include:

A. In the morning of 08/26/2014, in the security room, it was observed that the fire alarm control panel is not labeled as to the panel and circuit that serve it. NFPA 72 1999 1-5.2.5.2

During the document review process it was observed that testing and maintenance of the fire alarm system is not documented as required by NFPA 72. Failure of the fire alarm system to operate correctly will jeopardize all occupants of the building during a fire emergency.

Findings include:

A. In the morning of on 08/26/2014, during the document review process, records were not available to show monthly visual inspections of the fire alarm control batteries and semi-annual visual inspections of the horns and strobes as required by NFPA 72 1999 Table 7-3.1.

Based on random observation during the survey walk-through, accompanied by facility staff, not all rooms are provided with sprinkler protection as required by 19.3.5. This deficiency could affect patients, staff, and visitors if a fire is not quickly extinguished and spreads to other areas of the facility.

Findings include:

A. In the afternoon of 08/25/2014 and the morning of 08/26/2014, it was observed that the permanently built in wardrobes in the patient rooms are not provided with sprinkler heads, nor are there sprinkler heads located within one to three feet of the centerline of the door as required by CMS policy.

B. At 2:40 PM on 08/25/2014 in the central corridor, sprinkler protected rooms were observed that had missing ceiling tile, which is not in compliance with NFPA 13 1999 5-7.4.1.1. Locations include:

1. Telephone Equipment H-32
2. Electrical Equipment H-33

Based on document review, testing and maintenance of the sprinkler system is not documented as required by NFPA 25. Failure of the sprinkler system to operate correctly will jeopardize all occupants of the building during a fire emergency.

Findings include:

A. In the morning of 08/26/2014, during the document review process, records were not available to show weekly visual inspections of the backflow preventers, monthly visual inspections of the control valves, tamper switches, and gauges, annual visual inspection of the hangers and piping, and 5 year visual inspections of the interiors of the alarm and check valves, strainers, and piping as required by NFPA 25 1998 Table 2-1 and 9-1.

Based on document review, testing and maintenance of the sprinkler system is not documented as required by NFPA 25. Failure of the sprinkler system to operate correctly will jeopardize all occupants of the building during a fire emergency.

Findings include:

A. In the morning of 08/26/2014, during the document review process, records were not available to show weekly visual inspections of the backflow preventers, monthly visual inspections of the control valves, tamper switches, and gauges, annual visual inspection of the hangers and piping, and 5 year visual inspections of the interiors of the alarm and check valves, strainers, and piping as required by NFPA 25 1998 Table 2-1 and 9-1.

B. At 2:14 PM on 08/25/2014, it was observed that there is no sprinkler wrench located in the spare sprinkler head cabinet as required by NFPA 25 1998 2-4.1.6.

Based on document review, the facility failed to ensure that the range hood fire extinguishing system was inspected in accordance with 9.2.3 as well as NFPA 96. This deficiency could affect patients, staff, and visitors in the event of a cooking related fire.
Findings include:

A. In the morning of 08/26/2014, during record review, it was determined that there is no documentation that the required monthly visual inspection of the Kitchen Hood (ANSUL) located in the dietary prep room has been completed as required by NFPA 17A 1998 5-2.1.

Based on random observation during the survey walk-through, accompanied by facility staff, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke to enter the egress corridor.

Findings include:

A. At 12:37 PM on 08/26/2014 in the corridor that serves the X-Ray Suite, a waiting area which is not constantly attended and which is open to the adjacent corridor, was observed to lack smoke detectors required by Subpart (b) of Exception 2 to 19.3.6.1.

Based on random observation during the survey walk-through, accompanied by facility staff, the facility failed to maintain automatic closing for smoke barrier doors. This deficiency could affect patients, staff, and visitors in the Hinton and Brunk units if the doors do not close properly and smoke was allowed to pass from one smoke zone to another smoke zone.
Findings include:

A. At 8:37 AM on 08/26/2014 at the staff conference room behind the Hinton unit nurses ' station, a door in the smoke barrier between the Hinton and Brunk units was observed to be not self closing as required by 19.3.7.6

Based on random observation during the survey walk-through, accompanied by facility staff, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2. These deficiencies could affect all patients, staff, and visitors within the smoke compartment of the location by allowing smoke and fire to escape from hazardous rooms into the exit access corridor.

Findings include:

A. At 9:05 AM on 08/26/2014 in the mechanical room located at the northwest corner of the building it was observed that there are unsealed penetrations through the east wall. 19.3.2.1

Based on random observation during the survey walk-through, accompanied by facility staff, the facility failed to provide a fire alarm system with approved components, devices or equipment installed according to NFPA 72. This deficiency would affect all patients, staff, and visitors if a fire would start.

Findings include:

A. At 2:10 PM on 08/25/2014 in the electrical room it was observed that the fire alarm control panel is not labeled as to the panel and circuit that serve it. NFPA 72 1999 1-5.2.5.2

Based on random observation during the survey walk-through, accompanied by facility staff, the facility failed to provide a fire alarm system with approved components, devices or equipment installed according to NFPA 72. This deficiency would affect all patients, staff, and visitors if a fire would start.

Findings include:

A. In the morning of 08/26/2014, in the security room, it was observed that the fire alarm control panel is not labeled as to the panel and circuit that serve it. NFPA 72 1999 1-5.2.5.2

During the document review process it was observed that testing and maintenance of the fire alarm system is not documented as required by NFPA 72. Failure of the fire alarm system to operate correctly will jeopardize all occupants of the building during a fire emergency.

Findings include:

A. In the morning of on 08/26/2014, during the document review process, records were not available to show monthly visual inspections of the fire alarm control batteries and semi-annual visual inspections of the horns and strobes as required by NFPA 72 1999 Table 7-3.1.

Based on random observation during the survey walk-through, accompanied by facility staff, not all rooms are provided with sprinkler protection as required by 19.3.5. This deficiency could affect patients, staff, and visitors if a fire is not quickly extinguished and spreads to other areas of the facility.

Findings include:

A. In the afternoon of 08/25/2014 and the morning of 08/26/2014, it was observed that the permanently built in wardrobes in the patient rooms are not provided with sprinkler heads, nor are there sprinkler heads located within one to three feet of the centerline of the door as required by CMS policy.

B. At 2:40 PM on 08/25/2014 in the central corridor, sprinkler protected rooms were observed that had missing ceiling tile, which is not in compliance with NFPA 13 1999 5-7.4.1.1. Locations include:

1. Telephone Equipment H-32
2. Electrical Equipment H-33

Based on document review, testing and maintenance of the sprinkler system is not documented as required by NFPA 25. Failure of the sprinkler system to operate correctly will jeopardize all occupants of the building during a fire emergency.

Findings include:

A. In the morning of 08/26/2014, during the document review process, records were not available to show weekly visual inspections of the backflow preventers, monthly visual inspections of the control valves, tamper switches, and gauges, annual visual inspection of the hangers and piping, and 5 year visual inspections of the interiors of the alarm and check valves, strainers, and piping as required by NFPA 25 1998 Table 2-1 and 9-1.

Based on document review, testing and maintenance of the sprinkler system is not documented as required by NFPA 25. Failure of the sprinkler system to operate correctly will jeopardize all occupants of the building during a fire emergency.

Findings include:

A. In the morning of 08/26/2014, during the document review process, records were not available to show weekly visual inspections of the backflow preventers, monthly visual inspections of the control valves, tamper switches, and gauges, annual visual inspection of the hangers and piping, and 5 year visual inspections of the interiors of the alarm and check valves, strainers, and piping as required by NFPA 25 1998 Table 2-1 and 9-1.

B. At 2:14 PM on 08/25/2014, it was observed that there is no sprinkler wrench located in the spare sprinkler head cabinet as required by NFPA 25 1998 2-4.1.6.

Based on document review, the facility failed to ensure that the range hood fire extinguishing system was inspected in accordance with 9.2.3 as well as NFPA 96. This deficiency could affect patients, staff, and visitors in the event of a cooking related fire.
Findings include:

A. In the morning of 08/26/2014, during record review, it was determined that there is no documentation that the required monthly visual inspection of the Kitchen Hood (ANSUL) located in the dietary prep room has been completed as required by NFPA 17A 1998 5-2.1.

OTHER DEFICIENCY NOT ON 2786

This STANDARD is not met as evidenced by:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the
survey walk-through, the provider shall institute the 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 random observation during the survey walk-through, accompanied by facility staff, and in staff interviews, the division of the emergency electrical system into life safety, critical, and equipment branches as required by NFPA 99 1999 could not be verified.

Findings include:

A. In the morning of 08/26/2014, in the electrical room, the locations of the life safety, critical branch, and equipment electrical panels were not known to the staff accompanying the surveyor so the load distribution and division of the circuiting could not be verified. NFPA 99 1999 3-4.2.2.2