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Based on random observation during the survey walk-through, the surveyor and facility's manager observed that not all doors in exit access corridors are in compliance with 18.3.6.3.

Findings include:

A. Auto-opening doors within a means of egress do not comply with 7.2.1.such that in the event of power failure, fire alarm conditions, the door is to open manually. During the walk through and test of the fire alarm system the following doors were observed:

1. 11:15 am, a pair of auto opening doors from the Emergency Department (located adjacent to exam room # 3), did not drop out to manual activation to comply with 7.2.1.9.2

2. 11:52 am, an auto opening door from the Out Patient Department did not drop out to manual activation to comply with 7.2.1.9.2

This deficiency could allow smoke to move from areas into the exit access corridor which affects all patients in the Emergency department and the Out Patient department along with staff and visitors.



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Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building to comply with 18.3.2.1. These deficiencies could affect kitchen staff as well as persons within the conference room by allowing smoke and fire to escape from hazardous rooms into the building's adjacent areas.

Finding includes:

A. 10:30am, the Kitchen's "Servery " room (greater than 50 s.f.) adjacent to the Conference room was observed to contain multiple typing/printing paper packages of 500 sheets each. This room was deemed as a serving area for the Conference room and is currently being used as storage. Doors to this hazardous room were observed that do not carry a minimum 3/4 hour fire resistance rating to comply with 18.3.2.1. and 8.2.3.2.3.1(2). Locations observed include:
1. The sliding door to the Conference room.

2. The entry door from the Kitchen.




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Based on random observation during the survey walk-through, not all exit access is arranged so that exits are readily accessible at all times to comply with 18.2.1. This deficiency could affect patients within the physical therapy suite, staff and visitors by diminishing the required width of an exit access corridor and extending the amount of time for persons to safely reach an exit discharge from the building.



Finding includes:

A. 12:15pm, the following condition was observed by the surveyor and the facility representative at a corridor door from Pharmancy which does not comply with 7.2.1.4.4.:
1. The corridor door from Pharmacy was observed to protrude more than 7" into the exit access corridor when in the fully open position. The door only opened 90 degrees rather than 180 degrees, thereby diminishing the required width of the corridor.




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Based on staff interview during the document review, not all portions of the facility's sprinkler system complys with NFPA 13 1999 chapter 2 and chapter 9.

Finding includes:

A. During the document review process with the facility's manager on the morning of May 4, 2011, the records for the inspection and maintenance of the Automatic Sprinkler System could not be provided by the Facility. This deficiency can lead to poorly maintained system which can fail during an emergency affecting patients, staff and visitors.




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Based on random observation and staff interview during the survey walk-through, not all portions of the facility's commercial cooking equipment is installed to comply with NFPA 96 and 17, 1998.

Finding includes:


A. 10:45 am - During the survey walk-through of the Dietary Department the following conditions were observed by the surveyor and facility representative, within the Kitchen that do not comply with NFPA 96, 7-2.1, 7-2.2 and 7-5.1;

1. The manual activation device for the hood suppression system was observed to not clearly identify the hazard protected in order to comply with NFPA 17, 1998 2-4.2.2.

The lack of clearly identifiable operating instructions could create the possibility for a fire situation affecting kitchen staff and persons in the cafeteria.






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Based on random 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.

Finding includes:


A. 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 random observation during the survey walk-through, the surveyor and facility's manager observed that not all doors in exit access corridors are in compliance with 18.3.6.3.

Findings include:

A. Auto-opening doors within a means of egress do not comply with 7.2.1.such that in the event of power failure, fire alarm conditions, the door is to open manually. During the walk through and test of the fire alarm system the following doors were observed:

1. 11:15 am, a pair of auto opening doors from the Emergency Department (located adjacent to exam room # 3), did not drop out to manual activation to comply with 7.2.1.9.2

2. 11:52 am, an auto opening door from the Out Patient Department did not drop out to manual activation to comply with 7.2.1.9.2

This deficiency could allow smoke to move from areas into the exit access corridor which affects all patients in the Emergency department and the Out Patient department along with staff and visitors.



.

Based on random observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building to comply with 18.3.2.1. These deficiencies could affect kitchen staff as well as persons within the conference room by allowing smoke and fire to escape from hazardous rooms into the building's adjacent areas.

Finding includes:

A. 10:30am, the Kitchen's "Servery " room (greater than 50 s.f.) adjacent to the Conference room was observed to contain multiple typing/printing paper packages of 500 sheets each. This room was deemed as a serving area for the Conference room and is currently being used as storage. Doors to this hazardous room were observed that do not carry a minimum 3/4 hour fire resistance rating to comply with 18.3.2.1. and 8.2.3.2.3.1(2). Locations observed include:
1. The sliding door to the Conference room.

2. The entry door from the Kitchen.




.

Based on random observation during the survey walk-through, not all exit access is arranged so that exits are readily accessible at all times to comply with 18.2.1. This deficiency could affect patients within the physical therapy suite, staff and visitors by diminishing the required width of an exit access corridor and extending the amount of time for persons to safely reach an exit discharge from the building.



Finding includes:

A. 12:15pm, the following condition was observed by the surveyor and the facility representative at a corridor door from Pharmancy which does not comply with 7.2.1.4.4.:
1. The corridor door from Pharmacy was observed to protrude more than 7" into the exit access corridor when in the fully open position. The door only opened 90 degrees rather than 180 degrees, thereby diminishing the required width of the corridor.




.

Based on staff interview during the document review, not all portions of the facility's sprinkler system complys with NFPA 13 1999 chapter 2 and chapter 9.

Finding includes:

A. During the document review process with the facility's manager on the morning of May 4, 2011, the records for the inspection and maintenance of the Automatic Sprinkler System could not be provided by the Facility. This deficiency can lead to poorly maintained system which can fail during an emergency affecting patients, staff and visitors.




.

Based on random observation and staff interview during the survey walk-through, not all portions of the facility's commercial cooking equipment is installed to comply with NFPA 96 and 17, 1998.

Finding includes:


A. 10:45 am - During the survey walk-through of the Dietary Department the following conditions were observed by the surveyor and facility representative, within the Kitchen that do not comply with NFPA 96, 7-2.1, 7-2.2 and 7-5.1;

1. The manual activation device for the hood suppression system was observed to not clearly identify the hazard protected in order to comply with NFPA 17, 1998 2-4.2.2.

The lack of clearly identifiable operating instructions could create the possibility for a fire situation affecting kitchen staff and persons in the cafeteria.






.

Based on random 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.

Finding includes:


A. 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.