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Based on observation, the facility failed to maintain the building for compliance with the required construction types. This deficiency could affect patients, staff, and visitors in the event of the building being compromised during a fire emergency.

Findings include:

On 11/14/2016, accompanied by AD, wood ceiling framing was observed in the toilet rooms of the rooms listed below. The amount of wood framing could not be verified. This does not comply with 19.1.6.1.

A. 2:30 PM, in the second floor Administrative Director ' s office

B. 2:47 PM, in the 2 North Day Room

Based on observation, not all paths of egress are maintained free of obstructions and available for full instant use in the case of an emergency. This deficiency could affect patients, staff, and visitors in the event of a fire or other emergency.

Findings include:

A. On 11/14/2016 at 1:55 PM, accompanied by AD, on the fifth floor, exit signage was observed that directs the path of egress from a corridor into the east day room, which is being used for combustible storage. This does not comply with 7.5.2.1.

B. On 11/14/2016 at 3:13 PM, accompanied by AD, one of the doors marked as an exit from the first floor employee cafeteria opens into a stair which does not provide the 6 ' -8 " of head room required by 7.1.5.1.

C. On 11/14/2016 at 3:27, accompanied by AD, several laundry carts were observed blocking the first floor service corridor, which serves as an exit access corridor. This does not comply with 7.1.10.1.

Based on observation, not all egress doors are provided with hardware that allows for egress without the use of a tool or key. This deficiency could affect staff or visitors on the floor where the doors are located from exiting in the event of an emergency.

Findings include:

On 11/14/2016 at 1:50 PM, accompanied by AD, the exit stair doors that serve the fifth floor were observed to be provided with locks that require a key to open. This floor is identified as a business occupancy, and the locks are not in compliance with 39.2.2.2.2 and 7.2.1.5.3.

Based on observation, not all doors that are required to be self closing are maintained so that they close and latch. This deficiency could jeopardize the integrity of an exit stair in the event of a fire in the adjacent space and affect all visitors, patients and staff.

Findings include:

On 11/14/2016 at 3:12 PM, accompanied by AD, the door from the first floor kitchen that opens into the west exit stair was observed to be held open by air pressure. This does not comply with 19.2.2.2.7.

Based on observation, not all stair doors are maintained to retain their required fire rating. This deficiency could jeopardize the integrity of an exit stair in the event of a fire in the adjacent space and could affect all visitors, patients and staff.

Findings include:

On 11/14/2016, accompanied by AD, fire rated doors at exit stair enclosures were observed to have been modified with field applied plates that aren ' t labeled as required by NFPA 80 2010 5.2.15.3. Locations include:

A. 2:15 PM, at the fifth floor north wing stair

B. 2:37 PM, at the second floor west stair

Based on observation during the survey walk-through, not all the exit discharge had 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 11-15-201616 at 9:30 AM, accompanied by MPO, a 3 ' x4 ' concrete stoop was observed at the southwest exit discharge that does not terminate to the public way, not in compliance with the Sections 39.2.7, 7.7 and CMS Memo S&C 05-38.

Based on observation during the survey walk-through, not all the exit discharge is arranged by either continuous in operation or capable of automatic operation without manual intervention.

Findings include:

On 11-15-2016 at 9:50 AM, accompanied by MPO, north and southwest exit discharge was installed with only one bulb light fixture instead of two bulb light fixture or two single bulb light fixtures, not in compliance with Sections 39.2.8 and 7.8.

Based on observation, not all hazardous areas are separated by smoke resisting partitions and doors. This deficiency could affect all occupants in the smoke compartment if a fire occurred in the hazardous area.

Findings include:

On 11/15/2016 at 10:12 AM, accompanied by AD, the door to the first floor medical records storage room was observed to not be self closing as required by 19.3.2.1.3.

Based on observation, not all spaces open to an exit access corridors are protected with smoke detection. This deficiency could compromise the corridor in the event of a fire in the space and affect visitors, patients and staff.
Findings include:

On 11/15/2016 at 10:32 AM, accompanied by AD, the first floor mail room was observed to be open to the exit access corridor but lacked smoke detection as required by 19.3.6.1.

Based on observation during the survey walk-through, not all the areas are protected with automatic sprinkler system. This deficiency could affect all patients and staff in the event that a fire started in the unsprinklered areas.

Findings include:

On 11/14-15/2016 , accompanied by MPO, electrical closets measuring 60 " x19 " in the in the flowing locations do not have sprinkler protection and are not in compliance with Sections 19.3.5.1, 9.7, 9,7.1.1 (1) and NFPA 13.

A. On 11/14/2016 at 2:25 PM - Elevator Lobby

B. On 11/15/2016 at 10:15 AM - Next to the Third Floor Electrical Room

C. On 11/15/2016 at 10:42 - Next to the Fourth Floor Electrical Room

D. On 11/15/2016 at 11:15 AM - Next to the Fifth Floor Electrical Room

Based on observation, the facility has not provided the required maintenance or level of protection for sprinkler related equipment. This deficiency could compromise the sprinkler system in the event of a fire in an adjacent space or a failure of the equipment and affect all visitors, patients and staff in the area.

Findings include:

A. On 11/15/2016 at 10:40 AM, accompanied by AD, walls at the fire pump room were observed to be incomplete instead providing of the 1 hour rating required by NFPA 20 2010 4.12.1.1.2.

B. On 11/15/2016 at 10:40 AM, accompanied by AD, the fire pump room was observed to be used for general storage and oxygen storage and is not dedicated to the fire pump as required by NFPA 20 2010 4.12.1.1.4.

C. On 11/15/2016 at 9:07 AM, during document review accompanied by MPO, documentation of the following testing and maintenance required by NFPA 25 2011 5.1.1.2 was requested but was not available:

1. Annual inspection of entire system
2. Five year replacement or recalibration of gauges

Based on observation, not all corridor doors are provided with the hardware necessary to keep them closed. This deficiency could allow smoke from within the room to enter the corridor during a fire and affect all visitors, patients and staff.

Findings include:

On 11/15/2016 at 11:08 AM, accompanied by AD, the corridor door at the fourth floor north quiet room is equipped with a pull only and does not latch as required by 19.3.6.3.5.

Based on observation, the elevator equipment is not isolated. This deficiency could result in a failure of the equipment if exposed to fire and affect all visitors, patients and staff.

Findings include:

On 11/15/2016 at 10:17 AM, accompanied by AD, elevator equipment was observed to be located in a room that is open to the paint storage/laundry room, not a dedicated room as required by ASME A17.3 2008 2.2.1.

Based on document review, the facility does not conduct fire drills as required. This deficiency could have a negative impact on staff ' s effectiveness during a fire emergency and affect visitors and patients.

Findings include:

A. On 11/15/2016 at 8:50 AM, accompanied by MPO, documentation that the fire alarm transmits a signal during fire drills as required by 19.7.1.4 was requested but was not available.

B. On 11/15/2016 at 8:57 AM, accompanied by MPO, documentation of the times of fire drills was reviewed and found that fire drills are not conducted at varying times as required by 19.7.1.6.

Times include:
Shift 1: 9:00 AM, 11:15 AM, 11:00 AM
Shift 2: 4:35 PM, 4:15 PM, 4:15 PM
Shift 3: 3:00 AM, 1:30 AM, 3:00 AM

Based on observation, the facility is not provided with a Type 1 Emergency Electrical System. This deficiency could affect all patients requiring critical care during the event of a power outage.

Findings include:

On 11/14/16 at 2:00 PM, while accompanied by the MPO, it was observed that the emergency electrical system was a Type 2 system. The facility did not provide a written risk assessment to justify the Type 2 system.