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Based on observation during the survey walk-through, not all stairs are constructed and maintained in accordance with 19.2.2.3 and 7.2. These deficiencies could affect all persons required to utilize the exit components by preventing those occupants from safely reaching an exit from the building.

Findings include:

A. Completed 3/10/2015

B. Completed 3/10/2015

C. Completed 3/10/2015

D. Completed 3/10/2015

E. At 10:00am on 7/22/14 it was observed that the exterior stair from the east wing exit stair discharge lacked hand railings extending the full length of the stair treads and risers to comply with 7.2.2.4.3. The bottom tread was elevated above ground surface and was greater than 3/16" difference from remaining tread depths in non-compliance with 7.2.2.3.6.

Based on an observation and interview, the facility failed to provide exit access that is arranged so that the exits are readily accessible at all times. This deficient practice could affect patients, staff and visitors if an evacuation via this deficient means of egress was necessary.

Findings include: On 3/10/2015 at 10:50 AM while accompanied by the Director of facilities it was determined by and observation and interview that the facility did not provide a solid walking surface from the exit discharge to the public way. This does not comply with NFPA 101, section 7.7.1

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 while accompanied by the Plant Operations Director, the surveyor found that the electrical system installation did not meet all requirements of NFPA-70. This could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

1. The surveyor observed that the elevator cab lights for the traction elevator were not fed from the life safety branch of emergency power in accordance with NFPA-70, Section 517-32.

2. The surveyor observed that the patient room headwalls were not equipped with critical power receptacles to meet the requirements of NFPA-70, Section 517-18, and 517-19.

3. Completed 3/10/2015

Based on an observation and interview, the facility failed to provide exit access that is arranged so that the exits are readily accessible at all times. This deficient practice could affect patients, staff and visitors if an evacuation via this deficient means of egress was necessary.

Findings include: On 3/10/2015 at 10:50 AM while accompanied by the Director of facilities it was determined by and observation and interview that the facility did not provide a solid walking surface from the exit discharge to the public way. This does not comply with NFPA 101, section 7.7.1