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Based on observations the facility failed to maintain the minimum Construction Type for this building. This deficient practice could compromise the fire resistant rating of the structure and affect patients, staff and visitors within a means of egress if fire compromised the structural integrity of the building.

Finding includes:

On 11\12\2019 at 11:10am while in the company of the FM, the surveyor observed unprotected structural steel members. Unprotected steel beams were observed. This condition does not comply with the requirements of 19.1.6.1 for construction type limitations for a 5 story healthcare building. The materials observed do not maintain a minimum 2-hour fire resistant rating.

Location observed: 5th floor corridor which leads to both the roof access door and Stair #8.

Based on observation, not all stairs or smokeproof enclosures (including stair components) are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained.

The finding is:

On 11\12\2019 , while in the company of the FM, it was observed that the distance between guardrails in exit stair enclosures was observed to be in excess of 4" at the landings which does not comply with 19.2.2.3, 7.2.2.4.5.3.
Example locations observed:

1. At 1:05pm Exit Stair #1

2. At 2:01pm Exit Stair #2

Based on observation, not all egress paths lead to an exit. This deficient practice could require a person to traverse a longer route to reach an exit. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The findings are:

A. On 11/12/2019 at 11:45am while accompanied by the FM, a corridor was observed directing exiting through the HAU suite to Exit Stair #1. This condition does not comply with 19.2.5.4 and 7.5.1.2. This condition a dead end condition which does not comply with 7.5.1.5.

B. On 11/12/2019 at 11:50am while accompanied by the FM, the means of egress from the third floor smoke compartment housing the HAU suite does not have two separate exits remotely located to comply with 19.2.4.3, 19.2.4.4 and 7.5.1.3.1.
Location observed: Third floor - pair of cross corridor smoke barrier doors adjacent to the nurse station with the distance from these doors to Exit Stair #8 entry door.

Based on observation, not all the exit discharges contained a hard packed all-weather travel surface leading to a public way. This could affect all occupants needing to exit the building, particularly in an emergency situation.

Findings include:

On 11/12/2019 while accompanied by the FM exit discharges was observed which do not provide a maintained slip resistant means of egress to the public way. This condition does not comply with the Sections 19.2.7, 7.7, 7.1.6.4 and 7.1.10.1 including CMS Memo S&C 05-38. Example locations include:

1. At 11:00am exterior exit discharge door for the Kitchen did not completely open due to the condition of the door being stuck requiring more than allowed by 7.2.1.4.5.

2. At 2:00pm Stair #4 exterior discharge path, was covered in ice and snow, no usable path provided.

3. At 3:45pm Stair #6 exterior discharge path, was covered in ice and snow, no usable path provided.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas 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.

The finding is:

On 11/13/2019 at 2:40pm while accompanied by the SFM, a corridor was observed which lacks designated access to two remote exits producing a dead end condition. This does not comply with 7.10 and 19.2.10.1.
Location observed: First floor 1927 building, parking lot side, designated exit to the exterior as viewed from Education area.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting.

The finding is:

On 11/13/2019, at 11:45am while in the company of the SFM, non sprinklered hazardous areas are not separated by fire resistant construction to include a fire rated self-closing door and frame assembly to comply with 19.3.2.1, 8.7.1, & 8.4.3.5. Location observed: electrical closet second floor corridor near the HAU suite.

Based on observation during the survey walk through the facility failed to document inspection of the kitchen hood fire suppression system. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 11/12/19 at 2:00 pm in the company of the FM observation of the inspection tag for the grease hood fire protection system was observed. The record of the date and initials of the person completing the monthly inspection is not provided on the tag to comply with NFPA, 17, 2009, 11.2.4 / NFPA 17A, 2009, 7.2.5.

Based on observation the facility failed to provide protection for the fire alarm components. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 11/13/19 at 12:15 pm while accompanied by the SFM, it was observed that the main fire alarm control panel located in the basement electrical room was not provided with smoke detection to comply with NFPA 72, 2010, 10.15.

Based on document review and interview, the facility failed to provide a properly functioning fire alarm system. This deficient practice could affect patients, staff and visitors if the fire alarm system failed to function properly during a fire event.

Findings include:

On 11/12/2019 at 4:00pm while accompanied by the FM, document review of the annual fire alarm inspection conducted in October 2019 indicated items which have failed inspection. There was no documentation which indicated any of the failed items have since been repaired or replaced. This does not comply with NFPA 72-2010, 10.5.7.3.1. For example:

1. The fourth floor mechancial room duct smoke detector by Waiting area failed.

2. The chimes failed at the following locations:
a. First floor by stair # 6,
b. The Main Lobby,
c. The Nurse Station on the third floor.

Based on observation and staff interview during the survey walk through the facility lacks complete fire sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

The findings is:

On 11/12/19 accompanied by the FM It was determined that the facilities elevator machine rooms are not provided with fire sprinkler protection to comply with NFPA 13, 2010, 8.1

Based on observation, not all portable wall hung fire extinguishers are maintained and accessible for use. This deficient practice could jeopardize the protection of patients, visitors and staff during a fire event by delaying access to a means of extinguishment.

The finding is:

On 11/12/2019 at 3:50pm while accompanied by the FM during document review fire extinguishers are not indicated to have been maintained to comply with NFPA 10, 2010 7.2.4.1. There is no log or record maintained which indicates the location and type of each fire extinguisher. The facility has no document in which to verify the exact number of extinguishers and their required location within the facility in order to comply with NFPA 10, 2010, 6.1.1.

Based on observations and staff interview, spaces open to the exit access corridor are not provided with protective features in accordance with Code requirements. Failure to provide protective features can compromise the use of the corridor when prompt notification of a fire/smoke event occurring within the space open to the exit corridor is not provided.

The finding is:

On 11/13/2019 at 1:30pm while in the company of SFM, Waiting rooms, not visually supervised by a nurse station, contain doors with self closing devices on hold opens that are not connected to the fire alarm system, due to this condition, smoke detection is to comply with Section 19.3.6.1 (2)(b).

Based on observation, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the area because smoke or fire could move from the separated rooms to the corridor doors are not properly installed and maintained.

The finding is:

On 11/13/2019 at 2:25pm, while accompanied by the SFM, a basement level corridor door lacked latching hardware to comply with 19.3.6.3.5 location observed Old Pharmacy which is now used as storage.

Based on document review the facility failed to provide required inspection and maintenance of fire protection appliances. Failure to maintain these installations could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 11/12/19 at 5:00 pm in the company of the FM documentation could not be provided for the 6 year inspection, testing and maintenance of the installed fire dampers and smoke dampers as required by NFPA 80, 2010, 19.4.1.1 and NFPA 105, 2010, 6.5.2. The last documented inspection provided was 2011.

Based on document review and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

Finding includes:

On 11/12/2019 at 4:25pm during document review with the FM, Facility fire drill documentation for the past 12 months did not indicate that staff are familiar with all drill procedures. Documentation does not indicate that staff on other floors are familiar with basic fire response procedures to comply with 19.7.1. and 4.7.2.
For example:

1. Fire Drill conducted on 06/13/19 the required remarks part of the form indicated that there was "no overhead page" "staff did not know location of emergency. Need to hold Dept leaders accoutable for staff understanding of code red procedures".

2. Fire Drill conducted on 10/13/19 the required remarks part of the form indicated that "security did not show up for the drill, only the staff on the unit showed up".

Based upon review of record documentation of door inspections, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. Failure to maintain doors can compromise adjacent spaces during a fire condition.

Finding includes:

On 11/12/2019 at 4:30pm while in the company of the FM, documentation for fire rated doors was reviewed. The following information was not available:
There is no indication a complete fire door inspection was conducted for 2019 to comply with any requirement of 7.2.1.15. For example:

1. There is no signed copy of inspections to comply with 7.2.1.15.4

2. There is no indication that the individuals who conduct the inspection comply with 7.2.1.15.5 for qualifications.

3. There is no indication that any doors requiring repair or modification have recieved them to comply with NFPA 80 2010, 5.1.5.1 for an immediate resolution.

4. There is no indication that any door has been inspected from both sides of the door to comply with 7.2.1.15.7.

Based on observation the facility failed to install a compliant Category 1 Medical Gas System. This deficient practice could result in the failure / response during a fire event, which may affect patients, staff and visitors.

The findings are:

On 11/13/19 at the following times and locations in the company of the SFM zone valves were observed installed within the same space for the outlets/inlets they control and not placed on a intervening wall. This condition does not comply with NFPA 99, 2012, 5.1.4.8. Locations observed:

1. At 10:10am Dialysis Unit
2. At 10:20am ABG Unit
3. At 10:42am Higher Acuity Unit
4. At 11: 05am Physical Therapy Unit