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Based on direct observation a non conforming building is not completely separated from a health care building by a fire rated barrier assembly. This deficient practice could affect any occupant of both buildings during the event of a fire in the non conforming building.

Findings include:

A. On 02/02/2016 at 2:50pm, while accompanied by the D.F.O and C.O.O. V.P., it was observed that the two hour fire rated barrier is not complete in several locations to comply with 19.1.1.4.1 at the 2nd floor between the chapel and maintenance area as described below:

1. A wood frame and door within the 2-hour barrier located in the Pantry (life safety code floor plans- issue date 03/20/2015) do not maintain the fire resistance of the barrier. This door is no longer used and therefore is considered part of the wall construction which does not provide a fire resistant barrier.

2. The door, frame and door hardware for the door located between the corridor to the maintenance shop and the corridor to the stair lack a U.L. listed design for the installation. The installation does not maintain the 2-hour fire resistant barrier.

3. The life safety floor plans do not indicate the continuation of the 2 hour barrier from outside wall to outside wall on the 1st floor or the 2nd floor. For example the 2-hour barrier is not indicated on the 1st floor between "breakroom" and "corridor".

Based on document review and staff interview the facility failed to provide a building with a required construction type. This deficient practice may, during a fire emergency, affect patients, staff and visitors from floor to floor and barrier to barrier in order to gain safe access to an adjacent compartment.

The finding is:

On 02/03/2016 at 2:00pm based upon interview with the D.F.O., the surveyor finds that the East Building, is constructed with reinforced concrete structural systems. However, the provider lacks historical data, U L Design Numbers, and/or other information which identifies the Construction Type of this building as defined by NFPA 220. The provider is not able to demonstrate that each building is at least Type II (222) construction, in accordance with 19.1.6.2. The facility's F.S.E.S. dated 2014 was observed to cover this deficiency, however, the F.S.E.S. is not updated/current.

Based on document review and staff interview the facility failed to provide a building with a required construction type. This deficient practice may, during a fire emergency, affect patients, staff and visitors from gaining safe access to a discharge.

The finding is:

On 02/03/2016 at 2:00pm based upon an interview with the D.F.O. the surveyor finds that the West Building is constructed with reinforced concrete structural systems. However, the provider lacks historical data, U L Design Numbers, and/or other information which identifies the Construction Type of this building as defined by NFPA 220. The provider is not able to demonstrate that this building is at least Type II (222) construction, in accordance with 19.1.6.2. The facility's F.S.E.S. dated 2014 was observed to cover this deficiency, however, the F.S.E.S. is not updated/current.

Based on document review and staff interview, the facility failed to provide a building with a required construction type. This deficient practice may, during a fire emergency, affect patients, staff and visitors from gaining safe access to a discharge.

The finding is:

A. On 02/03/2016 at 2:00pm based upon interview with the D.F.O., the surveyor finds that the Center Building is constructed with reinforced concrete structural systems. However, the provider lacks historical data, U L Design Numbers, and/or other information which identifies the Construction Type of this building as defined by NFPA 220. The provider is not able to demonstrate that this building is at least Type II (222) construction, to comply with 19.1.6.2. The facility's F.S.E.S. dated 2014 was observed to cover this deficiency, however, the F.S.E.S. is not updated/current.

B. On 02/03/2016 at 2:00pm based upon interview with the D.F.O., the surveyor finds Basement Level Center Building's Bed Storage/Furniture Storage Room is ribbed slab concrete construction with a monolithic plaster ceiling on the bottom of the concrete. This plaster ceiling has large voids in it. The provider's F.S.E.S. is not updated/current to demonstrate how the floor assembly is at least two hour rated without the plaster ceiling.

Based on direct observation the facility failed to separate use areas from means of egress corridors. Lack of properly separated use areas from means of egress corridors could result in the inability of staff to locate the smoke or fire and effectively evacuate occupants from the area.
Finding include:
On 02/02/2016 at 10:30AM, the surveyor observed while accompanied by the facility S.F.O. a Snack Room with two vending machines used by staff and visitors on First Floor of the North Building was open to the exit access corridor. This area was not under visual supervision and lacked smoke detectors in accordance with the 39.2.5.1. and 7.5.

Based on direct observation of means of egress corridors, the facility failed to adequately provide smoke tight corridor walls. This deficient practice could result in the inability of staff to locate the smoke or fire and effectively evacuate occupants from an area.
Finding include:
On 02/02/2016 at 10:35am, the surveyor observed while accompanied by the facility S.F.O., an office door to the exit access corridor located across from the Snack Room. The corridor door had a 2 inch diameter hole through it. This door was not capable of resisting the passage of smoke. Therefore, the Office door, is not in accordance with 39.2.5 and 7.2.1.

Based on observation, the facility failed to provide visible exit signage. This deficiency could affect all patients, visitors and staff if the exits could not be located.
Finding include:
A. On 02/02/2016 at 1:40pm while accompanied by the facility S.F.O., the surveyor observed when exiting from the same day surgery wing on the 4th floor, an exit sign which leads to the stair is blocked by a ceiling fixture. This condition does not comply with the NFPA 101 Sections 19.2.10.1 and 7.10.
B. On 02/02/2016 at 1:45pm while accompanied by the facility S.F.O., the surveyor observed an exit sign was not installed at the east end of the 4th floor elevator lobby at the pair of cross corridor doors leading to the same day surgery wing. This does not comply withthe NFPA 101 Sections 19.2.10.1 and 7.10.

Based on observation, the facility failed to separate hazardous areas from the remainder of the building. This deficient practice could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. On 02/03/16 at 10:30AM, while accompanied by the C.O.O. / V.P., the surveyor observed the OB Unit to be under construction. The construction area is a hazard which lacks a one hour fire rated separation from occupied locations.

Example locations:

1. The wall between the occupied C-Section Suite and the Nursery Unit, is not complete through the deck above, several duct and wiring penetrations are not fire sealed.
2. Window openings from the Nursery are not separated with fire rated construction. This does not comply with 19.3.2.1. and 8.4.1.1 (1).

B. On 02/02/16 at 10:30 AM, while accompanied by the C.O.O. / V.P. , the surveyor observed that a storage room within the 2nd floor Mental Health Unit contains stored donated clothes and items for patient's to use, lacks a self-closing door to comply with 19.3.2.1.


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C. On 02/03/2016 at 9:30am while accompanied by the facility S.F.O. the surveyor observed basement level storage rooms which are not separated from the means of egress corridor to comply with 19.3.2.1 due to the following:
1. Storage room adjacent to west end mechanical room contains an entry door with holes drilled through it which does not comply with NFPA 80.
2. The same door does not close to a latched position.
3. A pair of entry doors to a storage room which is located across from the Director of Environmental Services do not close to a latched position.
4. The entry door to the chute room does not maintain a fire rated door/frame installation to comply with NFPA 80. The door contains holes drilled through, the required depth of the door is compromised due to wear on the latch side of the door construction.
5. The "Clean Item storage room" is open to the means of egress corridor and does not comply with 19.3.6.4. due to a transfer opening using a fusible link.

Based on direct observation not all hazardous areas are separated from the remainder of the building. This deficient practice could affect all staff within the smoke compartment by allowing smoke and fire to escape from hazardous rooms into the exit access corridor.

A. 02/02/2016 at 11:15am, 5th floor, the surveyor observed while accompanied by the facility S.F.O. rooms being used for storage that are not shown as hazardous areas on the life safety floor plan to comply with 39.3.2.1 and 8.4.1.

Example locations include:

1. Open office # N578 located on the north/east end of the floor contains 32 cardboard banker boxes filled with documents/papers.

2. The vacant suite (1,115 s.f.) # N579 located adjacent to the Open office is an unoccupied area containing storage of mattresses, documents and other combustibles.


B. 02/02/2016 at 11:15am, 5th floor, the surveyor observed, while accompanied by the facility S.F.O., rooms being used for storage that are not separated from the means of egress corridor to comply with 39.3.2.1 and 8.4.1. Example locations include:

1. Open office# N578 located on the north/east end of the floor contains an entry door which is not self closing.

2. The vacant suite (1,115 s.f.)# N579 located adjacent to the Open office contains an entry door which is not self closing.

3. File room #N564 lacks a self closing entry door.

Based on direct observation, not all hazardous areas are separated from the remainder of the building. This deficient practice could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. On 02/02/2016, at 3:15pm while accompanied by the facility S.F.O., the surveyor observed an electrical closet within the Imaging suite adjacent to the Fluoroscopy room which did not comply with 19.3.2.1 for separation of hazardous areas due to the following:

1. The room lacks separation from adjacent spaces due to the following:
i The lack of sprinkler protection
ii. The lack of a drop-in ceiling.
iii. Conduit openings through the floor.
iv. Incomplete wall construction.
2. The room lacks a U.L. listed frame, door and door hardware. The door is not self closing.
3. The room lacks separation from overhead ductwork. Duct work running above is open allowing any fire event within this room to gain access to other locations within the building.

Based on direct observation the facility failed to provide a functional designated exit discharge. This deficient practice may affect staff within the area from exiting the space to a discharge during a fire/smoke event.

Findings include:

On 02/03/16 at 10:35, Basement, west end Mechanical room, the surveyor observed while accompanied by the facility C.O.O./V.P., a direct exit discharge door from the mechanical room which could not be opened. This installation does not comply with 19.2.4.1.

Based on direct observation not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This deficient practice may affect patients, staff and visitors on the upper floors from a safe means of egress to a discharge during a fire/smoke event.

Findings include:

On 02/02/16 at 10:35am, 3rd Floor Exit Stair #5, the surveyor observed while accompanied by the facility C.O.O./V.P., an access panel door which was not self-closing to comply with 8.2.5.4 (1) and 8.2.3.2.3.1(1).

Based on direct observation not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This deficient practice may affect patients, staff and visitors on the upper floors from a safe means of egress to a discharge during a fire/smoke event.

Findings include:

A. 02/02/2016 at 2:00pm, 2nd floor Exit Stair #7, the surveyor observed while accompanied by the facility S.F.O., a 5 story designated exit stair for both business and healthcare includes an exit passageway on each floor. The designated 2-hour fire rated exit passageway lacked separation and protection to comply with 19.3.2 and 7.1.3.2.1 (e).

Conditions observed include:

1. F.D. #40 ductwork which penetrates the exit passageway walls contained a vertical and horizontal gap between the duct and the 2 hour rated wall adjacent to office # N276. This installation does not appear to comply with the manufacturer's installation requirements or with NFPA 90A.
2. F.D. #40 no sheet metal flanges were observed on the through wall duct installation to comply with the manufacturer's installation requirements or with NFPA 90A.
3. Pipes and conduits penetrating the two hour fire rated wall near office #N276 and #N273 have annular spaces not sealed for a two hour fire rating.

Based on observation during the survey walk-through, exit stairs were not readily accessible at all times. 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 utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. On 02/02/16 at 10:30AM, Mental Health Unit on the 2nd Floor, while accompanied by the C.O.O. /.V.P. and the Maintenance Staff, the surveyor observed an Exit Stair Door, which is being equipped with a magnetic locking device only, which the magnet did not disengage to unlock for the rapid removal of occupants. This does not comply with 19.2.2.2.5.

B. On 02/02/16 at 10:35AM, De-tox Unit on the 2nd Floor, while accompanied by the C.O.O. /V.P. and the Maintenance Staff, the surveyor observed an Exit Stair Door, which was equipped with key locking hardware to which staff does not have a readily available key at all times to unlock the exit door. This does not comply with 19.2.2.2.2 Exception No. 2.

Based on observation the facility failed to provide exit accesses arranged so that exits are readily accessible at all times. These deficiencies could affect patients, visitors and staff in the building by preventing them from reaching an exit under fire conditions or other emergency situations:
Findings include:
1. 02/02/2016 at 2:35pm, at the exit door from 2nd floor Pharmacy, the surveyor observed while accompanied by the facility S.F.O. latching door hardware with a thumbturn deadbolt. This requires two operations for egress, and does not comply with 7.2.1.5.4.
2. On 02/02/2016 at 2:05 pm exit door from 4th floor Physical Therapy, the surveyor observed while accompanied by the facility S.F.O. latching door hardware with a thumbturn deadbolt. This requires two operations for egress instead of one operation, and is not in accordance with 7.2.1.5.4.

Based on observation, the facility failed to provide a compliant fire alarm system. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

A. On 02/03/16, at 10:15 AM, on First Floor, while accompanied by the C.O.O./ V.P. and the Maintenance Staff, the surveyor observed smoke detectors located within 3'-0" of supply air diffuser which does not comply with NFPA 72 1999 2-3.5.1.

Locations include:
1. OB Unit exit access corridor outside the Nursery Area.
2. Nursery Room.

B. On 02/02/16, at 10:40AM, Mental Health Unit on the 2nd Floor, while accompanied by the C.O.O./ V.P. and the Maintenance Staff, the surveyor observed egress double doors, which are equipped with magnetic hold-open devices, that did not drop-out during fire alarm activation. This does not comply with NFPA 101 Section 19.2.2.2.4 and 7.2.1.5.1.

Based on observation, the facility failed to provide a complete automatic sprinkler system. Failure to install a compliant sprinkler system could result in a delayed response that affects patients, staff and visitors.

Finding includes:

On 02/02/2016 at 3:15PM, while accompanied by the facility S.F.O., the surveyor observed variable temperature rating sprinkler heads within the same room/space. This was observed in the northeast portion of the Pharmacy on second floor of Center Building, not in accordance with the 19.1.6 and NFPA 13.


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B. On 2/2/16 at 10:56AM in the company of the Director of Facility Operations, it was observed that sprinkler protection was not provided under the lowest East stair landing. (NFPA 13, 1999, 5-13.3.2)

Based on observation not all portions of the fire protection sprinkler system are compliant. This could affect all occupants of the building because of incomplete suppression in a fire incident.
A. On 2/2/16 at 2:20PM in the company of the Director of Facility Operations it was observed that complete sprinkler protection was not provided at the Basement level of the west stairs. (NFPA 13, 1999, 5-1)
B. On 2/2/16 at 2:30PM in the company of the Director of Facility Operations it was observed that sprinkler protection was installed more than 6 inches below the structural obstructions in the Basement Chiller/Pump Mechanical Room. (NFPA 13, 1999, 5-6.4.1.2)

Based on direct observation the facility failed to install and maintain the sprinkler system. This deficient practice could result in failure of the sprinkler system and delayed response during a fire event, that may affect patients, staff and visitors.
Findings include:

A. On 2/2/16 at 10:30AM in the company of the Director of Facility Operations, the surveyor observed that sprinkler protection was not provided in two of two walk in cooler/freezers within the 1st floor Kitchen. (NFPA 13, 1999, 5-1)


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B. On 02/02/2016 at 10:20am, the surveyor observed while accompanined by the S.F.O., the 5th floor Bathroom #N0576 and the bathroom directly behind it were observed to not be provided with sprinkler protection in a building which is otherwise considered fully protected. The installation does not comply with NFPA 13 1999.

Based on document review, not all portions of the fire protection sprinkler system are maintained in compliance. This could affect all occupants of the building by not having the required water supply for suppression during a fire incident.
The finding is:
On 2/3/16 at 9:15AM in the company of the Director of Facility Operations during document review and staff interview, it was indicated that the annual testing of the fire pump is not completed while under emergency power. (NFPA 25, 1998, 5-3.3.4)

Not all portions of the fire protection sprinkler system are maintained in compliance with NFPA 25. This could affect all occupants of the building by not having the required water supply for suppression during a fire incident.
The finding is:
On 2/3/16 at 9:15AM in the company of the Director of Facility Operations, during document review and staff interview it was indicated that the annual testing of the fire pump is not completed while under emergency power. (NFPA 25, 1998, 5-3.3.4)

Not all portions of the fire protection sprinkler system are maintained in compliance with NFPA 25. This deficient practice could affect all occupants of the building by not having the required water supply for suppression during a fire incident.

The finding is:
On 2/3/16 at 9:15AM in the company of the Director of Facility Operations, during document review and staff interview, it was indicated that the annual testing of the fire pump is not completed while under emergency power. (NFPA 25, 1998, 5-3.3.4)

Based on observation, the facility failed to provide a secure vertical chute system. This deficient practice could affect patients, visitors and staff during a fire emergency by allowing smoke to gain access to other floor levels through an unsecured vertical chute.

Finding includes:

On 02/03/2016 at 10:15am while accompanied by the facility S.F.O. , the surveyor observed the use of padlocks on some trash and linen chutes open to means of egress corridors and the lack of any locking device on other chute openings does not comply with NFPA 82 1999 Edition. This condition was observed on all floors.

Based on observation, the facility failed to maintain egress paths free of obstructions or impediments. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

Findings include:

On 02/02/ 2016, at 10:00AM, 3rd floor ICU, while accompanied by facility C.O.O./V.P., the surveyor observed exit access corridors that contain nurse carts, equipment, patient bed, etc. These corridors are partially blocked and prevent the convenient removal of non ambulatory patients carried on stretchers during emergency conditions which does not comply with 19.2.3.3.

Based on observations and staff interviews during the survey walk-through, and based on document review, the surveyor finds the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

Findings include:

Due to the number, variety, and severity of the life safety code 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 observations and staff interviews during the survey walk-through, and based on document review, the surveyor finds the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

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 observations and staff interviews during the survey walk-through, and based on document review, the surveyor finds the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

The finding is:

Due to the number, variety, and severity of the life safety code 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, the facility failed to maintain proper electrical distribution requirements. This could affect any occupant during an outage of the normal power system.


Findings include:

On 02/02/2016 at 11:15 am while accompanied by the O.M. and E., the surveyor observed the 4th floor stage two recovery rooms were not equipped with receptacles served from a critical source of power to meet the requirements of the 1999 Edition of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.

Based on direct observation a non conforming building is not completely separated from a health care building by a fire rated barrier assembly. This deficient practice could affect any occupant of both buildings during the event of a fire in the non conforming building.

Findings include:

A. On 02/02/2016 at 2:50pm, while accompanied by the D.F.O and C.O.O. V.P., it was observed that the two hour fire rated barrier is not complete in several locations to comply with 19.1.1.4.1 at the 2nd floor between the chapel and maintenance area as described below:

1. A wood frame and door within the 2-hour barrier located in the Pantry (life safety code floor plans- issue date 03/20/2015) do not maintain the fire resistance of the barrier. This door is no longer used and therefore is considered part of the wall construction which does not provide a fire resistant barrier.

2. The door, frame and door hardware for the door located between the corridor to the maintenance shop and the corridor to the stair lack a U.L. listed design for the installation. The installation does not maintain the 2-hour fire resistant barrier.

3. The life safety floor plans do not indicate the continuation of the 2 hour barrier from outside wall to outside wall on the 1st floor or the 2nd floor. For example the 2-hour barrier is not indicated on the 1st floor between "breakroom" and "corridor".

Based on document review and staff interview the facility failed to provide a building with a required construction type. This deficient practice may, during a fire emergency, affect patients, staff and visitors from floor to floor and barrier to barrier in order to gain safe access to an adjacent compartment.

The finding is:

On 02/03/2016 at 2:00pm based upon interview with the D.F.O., the surveyor finds that the East Building, is constructed with reinforced concrete structural systems. However, the provider lacks historical data, U L Design Numbers, and/or other information which identifies the Construction Type of this building as defined by NFPA 220. The provider is not able to demonstrate that each building is at least Type II (222) construction, in accordance with 19.1.6.2. The facility's F.S.E.S. dated 2014 was observed to cover this deficiency, however, the F.S.E.S. is not updated/current.

Based on document review and staff interview the facility failed to provide a building with a required construction type. This deficient practice may, during a fire emergency, affect patients, staff and visitors from gaining safe access to a discharge.

The finding is:

On 02/03/2016 at 2:00pm based upon an interview with the D.F.O. the surveyor finds that the West Building is constructed with reinforced concrete structural systems. However, the provider lacks historical data, U L Design Numbers, and/or other information which identifies the Construction Type of this building as defined by NFPA 220. The provider is not able to demonstrate that this building is at least Type II (222) construction, in accordance with 19.1.6.2. The facility's F.S.E.S. dated 2014 was observed to cover this deficiency, however, the F.S.E.S. is not updated/current.

Based on document review and staff interview, the facility failed to provide a building with a required construction type. This deficient practice may, during a fire emergency, affect patients, staff and visitors from gaining safe access to a discharge.

The finding is:

A. On 02/03/2016 at 2:00pm based upon interview with the D.F.O., the surveyor finds that the Center Building is constructed with reinforced concrete structural systems. However, the provider lacks historical data, U L Design Numbers, and/or other information which identifies the Construction Type of this building as defined by NFPA 220. The provider is not able to demonstrate that this building is at least Type II (222) construction, to comply with 19.1.6.2. The facility's F.S.E.S. dated 2014 was observed to cover this deficiency, however, the F.S.E.S. is not updated/current.

B. On 02/03/2016 at 2:00pm based upon interview with the D.F.O., the surveyor finds Basement Level Center Building's Bed Storage/Furniture Storage Room is ribbed slab concrete construction with a monolithic plaster ceiling on the bottom of the concrete. This plaster ceiling has large voids in it. The provider's F.S.E.S. is not updated/current to demonstrate how the floor assembly is at least two hour rated without the plaster ceiling.

Based on direct observation the facility failed to separate use areas from means of egress corridors. Lack of properly separated use areas from means of egress corridors could result in the inability of staff to locate the smoke or fire and effectively evacuate occupants from the area.
Finding include:
On 02/02/2016 at 10:30AM, the surveyor observed while accompanied by the facility S.F.O. a Snack Room with two vending machines used by staff and visitors on First Floor of the North Building was open to the exit access corridor. This area was not under visual supervision and lacked smoke detectors in accordance with the 39.2.5.1. and 7.5.

Based on direct observation of means of egress corridors, the facility failed to adequately provide smoke tight corridor walls. This deficient practice could result in the inability of staff to locate the smoke or fire and effectively evacuate occupants from an area.
Finding include:
On 02/02/2016 at 10:35am, the surveyor observed while accompanied by the facility S.F.O., an office door to the exit access corridor located across from the Snack Room. The corridor door had a 2 inch diameter hole through it. This door was not capable of resisting the passage of smoke. Therefore, the Office door, is not in accordance with 39.2.5 and 7.2.1.

Based on observation, the facility failed to provide visible exit signage. This deficiency could affect all patients, visitors and staff if the exits could not be located.
Finding include:
A. On 02/02/2016 at 1:40pm while accompanied by the facility S.F.O., the surveyor observed when exiting from the same day surgery wing on the 4th floor, an exit sign which leads to the stair is blocked by a ceiling fixture. This condition does not comply with the NFPA 101 Sections 19.2.10.1 and 7.10.
B. On 02/02/2016 at 1:45pm while accompanied by the facility S.F.O., the surveyor observed an exit sign was not installed at the east end of the 4th floor elevator lobby at the pair of cross corridor doors leading to the same day surgery wing. This does not comply withthe NFPA 101 Sections 19.2.10.1 and 7.10.

Based on observation, the facility failed to separate hazardous areas from the remainder of the building. This deficient practice could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. On 02/03/16 at 10:30AM, while accompanied by the C.O.O. / V.P., the surveyor observed the OB Unit to be under construction. The construction area is a hazard which lacks a one hour fire rated separation from occupied locations.

Example locations:

1. The wall between the occupied C-Section Suite and the Nursery Unit, is not complete through the deck above, several duct and wiring penetrations are not fire sealed.
2. Window openings from the Nursery are not separated with fire rated construction. This does not comply with 19.3.2.1. and 8.4.1.1 (1).

B. On 02/02/16 at 10:30 AM, while accompanied by the C.O.O. / V.P. , the surveyor observed that a storage room within the 2nd floor Mental Health Unit contains stored donated clothes and items for patient's to use, lacks a self-closing door to comply with 19.3.2.1.


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C. On 02/03/2016 at 9:30am while accompanied by the facility S.F.O. the surveyor observed basement level storage rooms which are not separated from the means of egress corridor to comply with 19.3.2.1 due to the following:
1. Storage room adjacent to west end mechanical room contains an entry door with holes drilled through it which does not comply with NFPA 80.
2. The same door does not close to a latched position.
3. A pair of entry doors to a storage room which is located across from the Director of Environmental Services do not close to a latched position.
4. The entry door to the chute room does not maintain a fire rated door/frame installation to comply with NFPA 80. The door contains holes drilled through, the required depth of the door is compromised due to wear on the latch side of the door construction.
5. The "Clean Item storage room" is open to the means of egress corridor and does not comply with 19.3.6.4. due to a transfer opening using a fusible link.

Based on direct observation not all hazardous areas are separated from the remainder of the building. This deficient practice could affect all staff within the smoke compartment by allowing smoke and fire to escape from hazardous rooms into the exit access corridor.

A. 02/02/2016 at 11:15am, 5th floor, the surveyor observed while accompanied by the facility S.F.O. rooms being used for storage that are not shown as hazardous areas on the life safety floor plan to comply with 39.3.2.1 and 8.4.1.

Example locations include:

1. Open office # N578 located on the north/east end of the floor contains 32 cardboard banker boxes filled with documents/papers.

2. The vacant suite (1,115 s.f.) # N579 located adjacent to the Open office is an unoccupied area containing storage of mattresses, documents and other combustibles.


B. 02/02/2016 at 11:15am, 5th floor, the surveyor observed, while accompanied by the facility S.F.O., rooms being used for storage that are not separated from the means of egress corridor to comply with 39.3.2.1 and 8.4.1. Example locations include:

1. Open office# N578 located on the north/east end of the floor contains an entry door which is not self closing.

2. The vacant suite (1,115 s.f.)# N579 located adjacent to the Open office contains an entry door which is not self closing.

3. File room #N564 lacks a self closing entry door.

Based on direct observation, not all hazardous areas are separated from the remainder of the building. This deficient practice could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. On 02/02/2016, at 3:15pm while accompanied by the facility S.F.O., the surveyor observed an electrical closet within the Imaging suite adjacent to the Fluoroscopy room which did not comply with 19.3.2.1 for separation of hazardous areas due to the following:

1. The room lacks separation from adjacent spaces due to the following:
i The lack of sprinkler protection
ii. The lack of a drop-in ceiling.
iii. Conduit openings through the floor.
iv. Incomplete wall construction.
2. The room lacks a U.L. listed frame, door and door hardware. The door is not self closing.
3. The room lacks separation from overhead ductwork. Duct work running above is open allowing any fire event within this room to gain access to other locations within the building.

Based on direct observation the facility failed to provide a functional designated exit discharge. This deficient practice may affect staff within the area from exiting the space to a discharge during a fire/smoke event.

Findings include:

On 02/03/16 at 10:35, Basement, west end Mechanical room, the surveyor observed while accompanied by the facility C.O.O./V.P., a direct exit discharge door from the mechanical room which could not be opened. This installation does not comply with 19.2.4.1.

Based on direct observation not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This deficient practice may affect patients, staff and visitors on the upper floors from a safe means of egress to a discharge during a fire/smoke event.

Findings include:

On 02/02/16 at 10:35am, 3rd Floor Exit Stair #5, the surveyor observed while accompanied by the facility C.O.O./V.P., an access panel door which was not self-closing to comply with 8.2.5.4 (1) and 8.2.3.2.3.1(1).

Based on direct observation not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This deficient practice may affect patients, staff and visitors on the upper floors from a safe means of egress to a discharge during a fire/smoke event.

Findings include:

A. 02/02/2016 at 2:00pm, 2nd floor Exit Stair #7, the surveyor observed while accompanied by the facility S.F.O., a 5 story designated exit stair for both business and healthcare includes an exit passageway on each floor. The designated 2-hour fire rated exit passageway lacked separation and protection to comply with 19.3.2 and 7.1.3.2.1 (e).

Conditions observed include:

1. F.D. #40 ductwork which penetrates the exit passageway walls contained a vertical and horizontal gap between the duct and the 2 hour rated wall adjacent to office # N276. This installation does not appear to comply with the manufacturer's installation requirements or with NFPA 90A.
2. F.D. #40 no sheet metal flanges were observed on the through wall duct installation to comply with the manufacturer's installation requirements or with NFPA 90A.
3. Pipes and conduits penetrating the two hour fire rated wall near office #N276 and #N273 have annular spaces not sealed for a two hour fire rating.

Based on observation during the survey walk-through, exit stairs were not readily accessible at all times. 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 utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. On 02/02/16 at 10:30AM, Mental Health Unit on the 2nd Floor, while accompanied by the C.O.O. /.V.P. and the Maintenance Staff, the surveyor observed an Exit Stair Door, which is being equipped with a magnetic locking device only, which the magnet did not disengage to unlock for the rapid removal of occupants. This does not comply with 19.2.2.2.5.

B. On 02/02/16 at 10:35AM, De-tox Unit on the 2nd Floor, while accompanied by the C.O.O. /V.P. and the Maintenance Staff, the surveyor observed an Exit Stair Door, which was equipped with key locking hardware to which staff does not have a readily available key at all times to unlock the exit door. This does not comply with 19.2.2.2.2 Exception No. 2.

Based on observation the facility failed to provide exit accesses arranged so that exits are readily accessible at all times. These deficiencies could affect patients, visitors and staff in the building by preventing them from reaching an exit under fire conditions or other emergency situations:
Findings include:
1. 02/02/2016 at 2:35pm, at the exit door from 2nd floor Pharmacy, the surveyor observed while accompanied by the facility S.F.O. latching door hardware with a thumbturn deadbolt. This requires two operations for egress, and does not comply with 7.2.1.5.4.
2. On 02/02/2016 at 2:05 pm exit door from 4th floor Physical Therapy, the surveyor observed while accompanied by the facility S.F.O. latching door hardware with a thumbturn deadbolt. This requires two operations for egress instead of one operation, and is not in accordance with 7.2.1.5.4.

Based on observation, the facility failed to provide a compliant fire alarm system. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

Findings include:

A. On 02/03/16, at 10:15 AM, on First Floor, while accompanied by the C.O.O./ V.P. and the Maintenance Staff, the surveyor observed smoke detectors located within 3'-0" of supply air diffuser which does not comply with NFPA 72 1999 2-3.5.1.

Locations include:
1. OB Unit exit access corridor outside the Nursery Area.
2. Nursery Room.

B. On 02/02/16, at 10:40AM, Mental Health Unit on the 2nd Floor, while accompanied by the C.O.O./ V.P. and the Maintenance Staff, the surveyor observed egress double doors, which are equipped with magnetic hold-open devices, that did not drop-out during fire alarm activation. This does not comply with NFPA 101 Section 19.2.2.2.4 and 7.2.1.5.1.

Based on observation, the facility failed to provide a complete automatic sprinkler system. Failure to install a compliant sprinkler system could result in a delayed response that affects patients, staff and visitors.

Finding includes:

On 02/02/2016 at 3:15PM, while accompanied by the facility S.F.O., the surveyor observed variable temperature rating sprinkler heads within the same room/space. This was observed in the northeast portion of the Pharmacy on second floor of Center Building, not in accordance with the 19.1.6 and NFPA 13.


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B. On 2/2/16 at 10:56AM in the company of the Director of Facility Operations, it was observed that sprinkler protection was not provided under the lowest East stair landing. (NFPA 13, 1999, 5-13.3.2)

Based on observation not all portions of the fire protection sprinkler system are compliant. This could affect all occupants of the building because of incomplete suppression in a fire incident.
A. On 2/2/16 at 2:20PM in the company of the Director of Facility Operations it was observed that complete sprinkler protection was not provided at the Basement level of the west stairs. (NFPA 13, 1999, 5-1)
B. On 2/2/16 at 2:30PM in the company of the Director of Facility Operations it was observed that sprinkler protection was installed more than 6 inches below the structural obstructions in the Basement Chiller/Pump Mechanical Room. (NFPA 13, 1999, 5-6.4.1.2)

Based on direct observation the facility failed to install and maintain the sprinkler system. This deficient practice could result in failure of the sprinkler system and delayed response during a fire event, that may affect patients, staff and visitors.
Findings include:

A. On 2/2/16 at 10:30AM in the company of the Director of Facility Operations, the surveyor observed that sprinkler protection was not provided in two of two walk in cooler/freezers within the 1st floor Kitchen. (NFPA 13, 1999, 5-1)


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B. On 02/02/2016 at 10:20am, the surveyor observed while accompanined by the S.F.O., the 5th floor Bathroom #N0576 and the bathroom directly behind it were observed to not be provided with sprinkler protection in a building which is otherwise considered fully protected. The installation does not comply with NFPA 13 1999.

Based on document review, not all portions of the fire protection sprinkler system are maintained in compliance. This could affect all occupants of the building by not having the required water supply for suppression during a fire incident.
The finding is:
On 2/3/16 at 9:15AM in the company of the Director of Facility Operations during document review and staff interview, it was indicated that the annual testing of the fire pump is not completed while under emergency power. (NFPA 25, 1998, 5-3.3.4)

Not all portions of the fire protection sprinkler system are maintained in compliance with NFPA 25. This could affect all occupants of the building by not having the required water supply for suppression during a fire incident.
The finding is:
On 2/3/16 at 9:15AM in the company of the Director of Facility Operations, during document review and staff interview it was indicated that the annual testing of the fire pump is not completed while under emergency power. (NFPA 25, 1998, 5-3.3.4)

Not all portions of the fire protection sprinkler system are maintained in compliance with NFPA 25. This deficient practice could affect all occupants of the building by not having the required water supply for suppression during a fire incident.

The finding is:
On 2/3/16 at 9:15AM in the company of the Director of Facility Operations, during document review and staff interview, it was indicated that the annual testing of the fire pump is not completed while under emergency power. (NFPA 25, 1998, 5-3.3.4)

Based on observation, the facility failed to provide a secure vertical chute system. This deficient practice could affect patients, visitors and staff during a fire emergency by allowing smoke to gain access to other floor levels through an unsecured vertical chute.

Finding includes:

On 02/03/2016 at 10:15am while accompanied by the facility S.F.O. , the surveyor observed the use of padlocks on some trash and linen chutes open to means of egress corridors and the lack of any locking device on other chute openings does not comply with NFPA 82 1999 Edition. This condition was observed on all floors.

Based on observation, the facility failed to maintain egress paths free of obstructions or impediments. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

Findings include:

On 02/02/ 2016, at 10:00AM, 3rd floor ICU, while accompanied by facility C.O.O./V.P., the surveyor observed exit access corridors that contain nurse carts, equipment, patient bed, etc. These corridors are partially blocked and prevent the convenient removal of non ambulatory patients carried on stretchers during emergency conditions which does not comply with 19.2.3.3.

Based on observations and staff interviews during the survey walk-through, and based on document review, the surveyor finds the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

Findings include:

Due to the number, variety, and severity of the life safety code 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 observations and staff interviews during the survey walk-through, and based on document review, the surveyor finds the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

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 observations and staff interviews during the survey walk-through, and based on document review, the surveyor finds the facility is not in compliance with the life safety code and other code requirements that are documented under the K-tags of this survey.

The finding is:

Due to the number, variety, and severity of the life safety code 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, the facility failed to maintain proper electrical distribution requirements. This could affect any occupant during an outage of the normal power system.


Findings include:

On 02/02/2016 at 11:15 am while accompanied by the O.M. and E., the surveyor observed the 4th floor stage two recovery rooms were not equipped with receptacles served from a critical source of power to meet the requirements of the 1999 Edition of NFPA-70, Section 517-19 and NFPA-99, Section 3-3.2.1.2(a)1.