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Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection for 3 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (00) section 19.3.2.1. This deficient conditions could in the event of a fire, allow smoke and flames to spread throughout the effected corridors and areas making them untenable, which could negatively affect the exiting capabilities for residents, staff and visitors.


Findings include:

On facility tour between 9:00 AM to 5:30 PM on 09/30/2015, observation revealed, that the following deficient conditions hazardous storage rooms throughout the facility:

1. The soiled utility room SN 6054-6060 on the 6th floor had a door that did not positively latch into the frame,

2. the 5th floor storage room located across from room 5012 has double doors that had a gap that was greater than 1/4 of an inch,

3. the SDS patient room K is being used as a storage room for patient care carts that has a door that is not equipped with a self-closing device and would not positively close due to obstructions in the doors path.


This deficient condition was verified by the Facilities Management Director (KB).

Based on observations and an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9.3, and 19.2.9.1. This deficient practice could residents, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 9:00 AM to 5:30 PM on 09/30/2015, during the review of available emergency battery back up exit lighting maintenance documentation and interview with the Facilities Management Director (KB) revealed the that the facility failed to conduct 4 of 12 Monthly 30 second tests of the battery backup emergency lights.


This deficient condition was verified by the Facilities Management Director (KB).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:00 AM to 5:30 PM on 09/30/2015, observation revealed, that the following deficient conditions were identified:

1. There rare numerous smoke detectors that are located throughout the facility that are located within 36 inches of HVAC diffusers, and

2. the horn and strobes visual strobe light are not in sync.


This deficient condition was verified by the Facilities Management Director (KB).

Based on observations and staff interview, it was found that the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that would affect the residents, visitors and staff of the facility.

Findings include:

On facility tour between 9:00 AM to 5:30 PM on 09/30/2015, observations revealed that the following locations were not protected by the facility's fire sprinkler system:

1. Lower Level Data Room

2. the 2nd floor nurse call data room

3. the Labor and Delivery Department electrical room.



This deficient condition was verified by the Facilities Management Director (KB).

Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection for 3 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (00) section 19.3.2.1. This deficient conditions could in the event of a fire, allow smoke and flames to spread throughout the effected corridors and areas making them untenable, which could negatively affect the exiting capabilities for residents, staff and visitors.


Findings include:

On facility tour between 9:00 AM to 5:30 PM on 09/30/2015, observation revealed, that the following deficient conditions hazardous storage rooms throughout the facility:

1. The soiled utility room SN 6054-6060 on the 6th floor had a door that did not positively latch into the frame,

2. the 5th floor storage room located across from room 5012 has double doors that had a gap that was greater than 1/4 of an inch,

3. the SDS patient room K is being used as a storage room for patient care carts that has a door that is not equipped with a self-closing device and would not positively close due to obstructions in the doors path.


This deficient condition was verified by the Facilities Management Director (KB).

Based on observations and an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9.3, and 19.2.9.1. This deficient practice could residents, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 9:00 AM to 5:30 PM on 09/30/2015, during the review of available emergency battery back up exit lighting maintenance documentation and interview with the Facilities Management Director (KB) revealed the that the facility failed to conduct 4 of 12 Monthly 30 second tests of the battery backup emergency lights.


This deficient condition was verified by the Facilities Management Director (KB).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:00 AM to 5:30 PM on 09/30/2015, observation revealed, that the following deficient conditions were identified:

1. There rare numerous smoke detectors that are located throughout the facility that are located within 36 inches of HVAC diffusers, and

2. the horn and strobes visual strobe light are not in sync.


This deficient condition was verified by the Facilities Management Director (KB).

Based on observations and staff interview, it was found that the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that would affect the residents, visitors and staff of the facility.

Findings include:

On facility tour between 9:00 AM to 5:30 PM on 09/30/2015, observations revealed that the following locations were not protected by the facility's fire sprinkler system:

1. Lower Level Data Room

2. the 2nd floor nurse call data room

3. the Labor and Delivery Department electrical room.



This deficient condition was verified by the Facilities Management Director (KB).