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Based on observation during the survey walk-through, not all exit access corridors are separated from use areas. These deficiencies could affect any patients, staff, or visitors in the building by compromising the protection offered by the egress corridors.

Findings include:

While accompanied by the CFO and DF, the surveyor observed pipe or other penetrations in exit access corridor walls that are not sealed against the passage of smoke as required by 19.3.6.2.2. and 8.2.4.4.1. Locations observed include (all coaxial cables penetrating the wall above the room door):

A. April 13, 2016 at 1:18 PM: Patient Sleeping Room 114.

B. April 13, 2016 at 1:20 PM: Patient Sleeping Room 117.

C. April 13, 2016 at 1:48 PM: Patient Sleeping Room 147.

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:

On April 13, 2016, while accompanied by the CFO and DF, the surveyor observed penetrations (coaxial cables not sealed at both the joint between the wall and the cable sleeve and at the open end of the sleeve) above the cross-corridor doors 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.

A. 1:25 PM: Smoke barrier wall adjacent to patient Sleeping Room 106.

B. 1:42 PM: Smoke barrier wall adjacent to Emergency Department.

Based on observation during the survey walk-through, staff interview, and document review, 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:

A. On April 14, 2016 at 9:30 AM, during a review of the facility's building systems test records and while accompanied by the CFO and DF, 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 observation during the survey walk-through, staff interview, and document review, not all exit lighting is properly maintained. This deficiency could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

On April 14, 2016 at 9:35 AM, during a review of the facility's building systems test records and while accompanied by the CFO and DF, the surveyor determined that battery-powered exit lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.10.9.2. and 7.9.3.

Based on document review and staff interview, fire drills are not held at varying times and varying conditions. This deficeincy 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 April 14, 2016 at 9:30 AM, during a review of the facility's building systems test records and while accompanied by the CFO and DF, the surveyor determined that fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2015 and 2016, fire drills for the following quarters/shifts were conducted at the similar times listed:

A. First Shift:

1. September 18, 2015: 2:55 PM.

2. November 30,, 2015: 3:25 PM.

3. March 29, 2016: 3:25 PM.

B. Second Shift:

1. September 17, 2015: 10:25 PM.

2. November 30, 2015: 11:50 PM.

3. March 28, 2016: 11:00 AM.

Based on observation during the survey walk-through and staff interview, not all medical gas piping systems are installed and maintained as required. This deficiency could affect any patients in the cited area because the medical gas system could become compromised.

Findings include:

On April 13, 2016 at 12:30 PM, while accompanied by the CFO and DF, the surveyor observed that the Medical Gas Alarm Panel located on the south wall of the Nurses' Station indicated, via an illuminated warning signal, that the oxygen secondary liquid level was low. During an interview held at that time and location, the DF stated that the panel was not functioning properly. The panel is not properly alerting the facility to problems with the medical gas system in accordance with NFPA 99 1999 4-3.1.2.2(a).

Based on observation during the survey walk-through, not all duct penetrations at smoke barriers are protected against the passage of smoke. This deficiency could affect any patients, staff, or visitors in the building by permitting smoke to pass between smoke compartments.

Findings include:

On April 13, 2016 at 1:40 PM, while accompanied by the CFO and DF, the surveyor observed a duct penetrating the designated smoke barrier wall, at the north side of the Emergency Department Office, which is not equipped with a smoke damper as required by 19.3.7.3. and 8.3.5.1.

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:

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 observation during the survey walk-through and staff interview, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system. These deficiencies could affect any patients being treated in the facility's patient care areas because the Essential Electrical System (EES) could become compromised.

Findings include:

On April 13, 2016 at 12:45 PM, while accompanied by the CFO and DF, the surveyor observed that the electrical receptacles at the patient headwall in Patient Sleeping Room 114 are not labeled or color coded to demonstrate that each patient are area is provided with electrical receptacles served by at least two separate transfer switches as required by NFPA 70 199 517-18(a) and 517-19(a). During an interview held at that time and location, the DF confirmed that all patient care areas are similar.

Based on observation during the survey walk-through, not all exit access corridors are separated from use areas. These deficiencies could affect any patients, staff, or visitors in the building by compromising the protection offered by the egress corridors.

Findings include:

While accompanied by the CFO and DF, the surveyor observed pipe or other penetrations in exit access corridor walls that are not sealed against the passage of smoke as required by 19.3.6.2.2. and 8.2.4.4.1. Locations observed include (all coaxial cables penetrating the wall above the room door):

A. April 13, 2016 at 1:18 PM: Patient Sleeping Room 114.

B. April 13, 2016 at 1:20 PM: Patient Sleeping Room 117.

C. April 13, 2016 at 1:48 PM: Patient Sleeping Room 147.

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:

On April 13, 2016, while accompanied by the CFO and DF, the surveyor observed penetrations (coaxial cables not sealed at both the joint between the wall and the cable sleeve and at the open end of the sleeve) above the cross-corridor doors 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.

A. 1:25 PM: Smoke barrier wall adjacent to patient Sleeping Room 106.

B. 1:42 PM: Smoke barrier wall adjacent to Emergency Department.

Based on observation during the survey walk-through, staff interview, and document review, 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:

A. On April 14, 2016 at 9:30 AM, during a review of the facility's building systems test records and while accompanied by the CFO and DF, 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 observation during the survey walk-through, staff interview, and document review, not all exit lighting is properly maintained. This deficiency could affect any patients, staff, or visitors in the building by preventing them from safely exiting the building under fire conditions.

Findings include:

On April 14, 2016 at 9:35 AM, during a review of the facility's building systems test records and while accompanied by the CFO and DF, the surveyor determined that battery-powered exit lights are not tested for a period of 1-1/2 hours at least once each year as required by 7.10.9.2. and 7.9.3.

Based on document review and staff interview, fire drills are not held at varying times and varying conditions. This deficeincy 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 April 14, 2016 at 9:30 AM, during a review of the facility's building systems test records and while accompanied by the CFO and DF, the surveyor determined that fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar years 2015 and 2016, fire drills for the following quarters/shifts were conducted at the similar times listed:

A. First Shift:

1. September 18, 2015: 2:55 PM.

2. November 30,, 2015: 3:25 PM.

3. March 29, 2016: 3:25 PM.

B. Second Shift:

1. September 17, 2015: 10:25 PM.

2. November 30, 2015: 11:50 PM.

3. March 28, 2016: 11:00 AM.

Based on observation during the survey walk-through and staff interview, not all medical gas piping systems are installed and maintained as required. This deficiency could affect any patients in the cited area because the medical gas system could become compromised.

Findings include:

On April 13, 2016 at 12:30 PM, while accompanied by the CFO and DF, the surveyor observed that the Medical Gas Alarm Panel located on the south wall of the Nurses' Station indicated, via an illuminated warning signal, that the oxygen secondary liquid level was low. During an interview held at that time and location, the DF stated that the panel was not functioning properly. The panel is not properly alerting the facility to problems with the medical gas system in accordance with NFPA 99 1999 4-3.1.2.2(a).

Based on observation during the survey walk-through, not all duct penetrations at smoke barriers are protected against the passage of smoke. This deficiency could affect any patients, staff, or visitors in the building by permitting smoke to pass between smoke compartments.

Findings include:

On April 13, 2016 at 1:40 PM, while accompanied by the CFO and DF, the surveyor observed a duct penetrating the designated smoke barrier wall, at the north side of the Emergency Department Office, which is not equipped with a smoke damper as required by 19.3.7.3. and 8.3.5.1.

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:

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 observation during the survey walk-through and staff interview, the facility's electrical system is not divided into the critical branch, life safety branch, and the emergency system. These deficiencies could affect any patients being treated in the facility's patient care areas because the Essential Electrical System (EES) could become compromised.

Findings include:

On April 13, 2016 at 12:45 PM, while accompanied by the CFO and DF, the surveyor observed that the electrical receptacles at the patient headwall in Patient Sleeping Room 114 are not labeled or color coded to demonstrate that each patient are area is provided with electrical receptacles served by at least two separate transfer switches as required by NFPA 70 199 517-18(a) and 517-19(a). During an interview held at that time and location, the DF confirmed that all patient care areas are similar.