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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 2, 2016 at 9:31 AM, while accompanied by the OM, the surveyor observed two rooms, at the south end of the Fifth Floor South Wing Corridor, through which the egress path passes and which lack smoke detectors required by Subpart (c) of Exception 1 to 19.3.6.1.

Based on observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

While accompanied by the OM, the surveyor observed pipe or other penetrations in smoke barrier walls that are not sealed against the passage of smoke as required by 19.3.7.3. and 8.3.6.1. Locations observed include:

A. August 2, 2016, at 11:20 AM: Third Floor East Wing smoke barrier in the south East-West Corridor, data cables above the cross-corridor doors.

B. August 3, 2016, at 10:19 AM: First Floor Corridor, data cables above cross-corridor doors directly south of Office 1310.

C. August 3, 2016, at 10:24 AM: Third Floor East Wing smoke barrier in the south East-West Corridor, data cables above the cross-corridor doors.

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:

While accompanied by the OM, the surveyor observed hazardous areas at which the doors lack self-closing devices required by 19.3.2.1. Locations observed include:

A. August 2, 2016 at 12:58 PM: Fourth Floor Storage Room 4265.

B. August 3, 2016 at 10:14 AM: First Floor Laboratory Storage Room.

Based on observation during the survey walk-through, not all stair shafts used as exits are constructed as required. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

On August 3, 2016 at 10:31 AM, while accompanied by the OM, the surveyor observed that the guardrail at the First Floor landing for the Pain Clinic Exit Stair does not comply with 7.2.2.4.6.3 because a sphere greater than 4 inches in diameter cold pass between the guardrail elements.

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

Findings include:

A. On August 3, 2016 at 10:41 AM, while accompanied by the OM, the surveyor observed that the delayed egress lock at the Third Floor North Wing Exit Stair door did not release upon activation of the building fire alarm as required by 7.2.1.6.1(a).

B. On August 3, 2016, while accompanied by the OM, the surveyor observed the following deficiencies at the First Floor MRI Corridor:
1. 10:41 AM: The Corridor, because there is no exit sign leading occupants into the Radiology Department, lacks at least two remote exits as required by 19.2.5.9.

2. 10:42 AM: The egress path for the Corridor, which passes through the MRI Waiting Room, is obstructed by furniture as prohibited by 19.2.3.3 and 7.1.10.2 1.

Based on document review and staff interview, not all emergency lighting is properly maintained. This deficiency could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

On August 3, 2016, at 9:36 AM, while accompanied by the OM and while reviewing facility systems testing documentation, the surveyor determined that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3.

Based on document review and staff interview, 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 3, 2016, at 8:37 AM, while accompanied by the OM and while reviewing facility systems testing documentation, the surveyor determined that the facility does not verify the transmission of a fire alarm signal to the local Fire Department when conducting fire drills, as required by 19.7.1.2, because the Fire Department is not requested to confirm the signal receipt.

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 2, 2016, at 11:03 AM, while accompanied by the OM, the surveyor observed that the NAC Panel located in Third Floor Electrical Room 3335 is not labeled as to the electrical panel and circuit which serves it as required by NFPA 72 1999 1-5.2.5.2.

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, 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 2, 2016, while accompanied by the OM, the surveyor observed general care patient bed locations which lack at least two electrical receptacles served by the critical branch of the building's Type 1 Essential Electrical System (EES) as required by NFPA 70 1999 517-18(a). Locations observed include:
1. 9:22 AM: Fifth Floor West Wing GI Procedure Room.
2. 9:26 AM: Fifth Floor West Wing GI Recovery Bays.

B. On August 2, 2016 while accompanied by the OM, the surveyor observed critical care patient bed locations which lack at least two electrical receptacles 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. 12:56 PM: Fourth Floor Caesarian Section Room.

2. 1:22 PM: Fifth Floor Operating Room 4.

C. On August 2, 2016, while accompanied by the OM, the surveyor observed general care patient bed locations at which those electrical receptacles served by the critical branch of the building's Type 1 EES are not labeled as to the electrical panel and circuit which serves them as required by NFPA 70 1999 517-19(a). Locations observed include:

1. 11:02 AM: Fourth Floor LDR Rooms.

2. 12:57 PM: Fourth Floor Caesarian Section Room.

3. 1:25 PM: Fifth Floor PACU Stage I Recovery Bays.

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 2, 2016 at 9:31 AM, while accompanied by the OM, the surveyor observed two rooms, at the south end of the Fifth Floor South Wing Corridor, through which the egress path passes and which lack smoke detectors required by Subpart (c) of Exception 1 to 19.3.6.1.

Based on observation during the survey walk-through, not all designated or required smoke barrier walls are constructed or maintained as minimum 30 minute fire rated assemblies. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke to pass between smoke compartments.

Findings include:

While accompanied by the OM, the surveyor observed pipe or other penetrations in smoke barrier walls that are not sealed against the passage of smoke as required by 19.3.7.3. and 8.3.6.1. Locations observed include:

A. August 2, 2016, at 11:20 AM: Third Floor East Wing smoke barrier in the south East-West Corridor, data cables above the cross-corridor doors.

B. August 3, 2016, at 10:19 AM: First Floor Corridor, data cables above cross-corridor doors directly south of Office 1310.

C. August 3, 2016, at 10:24 AM: Third Floor East Wing smoke barrier in the south East-West Corridor, data cables above the cross-corridor doors.

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:

While accompanied by the OM, the surveyor observed hazardous areas at which the doors lack self-closing devices required by 19.3.2.1. Locations observed include:

A. August 2, 2016 at 12:58 PM: Fourth Floor Storage Room 4265.

B. August 3, 2016 at 10:14 AM: First Floor Laboratory Storage Room.

Based on observation during the survey walk-through, not all stair shafts used as exits are constructed as required. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings include:

On August 3, 2016 at 10:31 AM, while accompanied by the OM, the surveyor observed that the guardrail at the First Floor landing for the Pain Clinic Exit Stair does not comply with 7.2.2.4.6.3 because a sphere greater than 4 inches in diameter cold pass between the guardrail elements.

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

Findings include:

A. On August 3, 2016 at 10:41 AM, while accompanied by the OM, the surveyor observed that the delayed egress lock at the Third Floor North Wing Exit Stair door did not release upon activation of the building fire alarm as required by 7.2.1.6.1(a).

B. On August 3, 2016, while accompanied by the OM, the surveyor observed the following deficiencies at the First Floor MRI Corridor:
1. 10:41 AM: The Corridor, because there is no exit sign leading occupants into the Radiology Department, lacks at least two remote exits as required by 19.2.5.9.

2. 10:42 AM: The egress path for the Corridor, which passes through the MRI Waiting Room, is obstructed by furniture as prohibited by 19.2.3.3 and 7.1.10.2 1.

Based on document review and staff interview, not all emergency lighting is properly maintained. This deficiency could affect any patients, staff, or visitors in the building because the failure of the emergency lighting could prevent them from safely exiting the building under fire conditions.

Findings include:

On August 3, 2016, at 9:36 AM, while accompanied by the OM and while reviewing facility systems testing documentation, the surveyor determined that battery-powered emergency lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.9.3.

Based on document review and staff interview, 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 3, 2016, at 8:37 AM, while accompanied by the OM and while reviewing facility systems testing documentation, the surveyor determined that the facility does not verify the transmission of a fire alarm signal to the local Fire Department when conducting fire drills, as required by 19.7.1.2, because the Fire Department is not requested to confirm the signal receipt.

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 2, 2016, at 11:03 AM, while accompanied by the OM, the surveyor observed that the NAC Panel located in Third Floor Electrical Room 3335 is not labeled as to the electrical panel and circuit which serves it as required by NFPA 72 1999 1-5.2.5.2.

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, 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 2, 2016, while accompanied by the OM, the surveyor observed general care patient bed locations which lack at least two electrical receptacles served by the critical branch of the building's Type 1 Essential Electrical System (EES) as required by NFPA 70 1999 517-18(a). Locations observed include:
1. 9:22 AM: Fifth Floor West Wing GI Procedure Room.
2. 9:26 AM: Fifth Floor West Wing GI Recovery Bays.

B. On August 2, 2016 while accompanied by the OM, the surveyor observed critical care patient bed locations which lack at least two electrical receptacles 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. 12:56 PM: Fourth Floor Caesarian Section Room.

2. 1:22 PM: Fifth Floor Operating Room 4.

C. On August 2, 2016, while accompanied by the OM, the surveyor observed general care patient bed locations at which those electrical receptacles served by the critical branch of the building's Type 1 EES are not labeled as to the electrical panel and circuit which serves them as required by NFPA 70 1999 517-19(a). Locations observed include:

1. 11:02 AM: Fourth Floor LDR Rooms.

2. 12:57 PM: Fourth Floor Caesarian Section Room.

3. 1:25 PM: Fifth Floor PACU Stage I Recovery Bays.