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During the survey walk through it was observed that the facility failed to maintain the building to be in 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 12/28/2015 at 11:02 AM, accompanied by the Director of Facilities and a Maintenance Technician, combustible framing was observed in the soffits located in Nuclear Medicine 1413. This is not in compliance with 19.1.6.3.

During the survey walk through it was observed that the facility failed to maintain the building to be in 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 12/28/2015 at 1:10 PM, accompanied by the Director of Facilities and a Maintenance Technician, by staff interview, the sleep center is used for the treatment of inpatients and is thus a health care occupancy. By direct observation and staff interview, the modular building housing the sleep center was indicated to be of Type V(000) construction, which is not permitted in a new health care occupancy under 18.1.6.2.

During the survey walk-through, it was observed that not all doors in exit access corridors are provided with positive latching hardware. This deficiency could affect any patients, staff, or visitors in the immediate area by allowing smoke or fire to enter the egress corridor.

Findings include:

On 12/28/2015, accompanied by the Director of Facilities and a Maintenance Technician, the following corridor doors were observed to lack positive latching hardware as required by 19.3.6.3.2 and could be opened with minimal effort. Locations include:

1. At 2:06 PM, the north corridor doors at the OR suite
2. At 2:25 PM, the corridor door into the lower level IT suite
3. At 11:05 AM, the corridor door at the radiology suite

During the survey walk-through it was observed that exit signs did not identify a continuous path of egress in all cases. This deficiency could affect any patients, staff, or visitors in the cited area by preventing them from safely exiting the building under fire conditions.

Findings include:

On 12/28/15 at 1:10 PM, accompanied by the Director of Facilities and a Maintenance Technician, it was observed the vestibule from the sleep center into the main building did not have an exit sign as required by 19.2.10.1.

During the survey walk through, it was observed that not all exterior paths of egress to a public way are provided with surfaces that are maintainable under all weather conditions. This deficiency could affect any patients, staff, or visitors that might have to use a wheelchair or gurney to exit the building in an emergency.

Findings include:

On 12/28/2015, accompanied by the Director of Facilities and a Maintenance Technician, the following exterior doors were observed to be signed as exits but lacked a sidewalk or other maintainable surface from the door to a public way as required by 19.2.1 and 7.1.10.1.

1. At 10:00 AM, in the administrative area on the main level
2. At 1:15 PM, at the end of the corridor near the infusion unit on the main level
3. At 1:20 PM, at all exterior exit doors in the inpatient care wing

During the survey walk-through it was observed that exit access is not arranged so that exits are readily accessible at all times. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the building.

Findings include:

On 12/28/2015, accompanied by the Director of Facilities and a Maintenance Technician, the following doors were observed to be signed as exit access doors but were secured with magnetic locks that require a card to unlock and which are not in compliance with 19.2.2.2.4.

1. At 2:17 PM, the exit access doors from the emergency department
2. At 3:00 PM, the cross corridor doors between the building that houses the geriatric psych wing and the main building lower level.

Adequate fire protection sprinkler coverage is not provided within the main electrical switchgear room which leaves portion of the space unprotected in the event of a fire. This deficiency could affect all patients, visitors and staff in case of a fire emergency.
On 12/28/15 at 10:30am in the company of the Maintenance Technician, the surveyor observed that 2 of the 3 upright sprinkler heads installed had been rotated 90 degrees from the horizontal position.

This STANDARD is not met as evidenced by:


Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-thru, the provider shall institute the appropriate Interim Life Safety Measures until all cited deficiencies are corrected. The provider shall include, as an attachment to the 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 measure 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 the POC progresses.

This STANDARD is not met as evidenced by:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-thru, the provider shall institute the appropriate Interim Life Safety Measures until all cited deficiencies are corrected. The provider shall include, as an attachment to the 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 measure 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 the POC progresses.

During the survey walk through, it was observed that not all electrical work was in compliance. This deficiency could affect any patients if a transfer switch failed.

Findings include:

On 12/28/2015, accompanied by the Facility Electrician, it was observed that the following areas are not equipped with normal power receptacles as is required by NFPA 70 1999 517-18(a) and 517-19(a).

1. At 10:35 AM, the ER rooms
2. At 10:55 AM, the OR rooms
3. At 11:20 AM, the C-section room
4. At 1:15 PM, some of the patient rooms

During the survey walk through it was observed that the facility failed to maintain the building to be in 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 12/28/2015 at 11:02 AM, accompanied by the Director of Facilities and a Maintenance Technician, combustible framing was observed in the soffits located in Nuclear Medicine 1413. This is not in compliance with 19.1.6.3.

During the survey walk through it was observed that the facility failed to maintain the building to be in 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 12/28/2015 at 1:10 PM, accompanied by the Director of Facilities and a Maintenance Technician, by staff interview, the sleep center is used for the treatment of inpatients and is thus a health care occupancy. By direct observation and staff interview, the modular building housing the sleep center was indicated to be of Type V(000) construction, which is not permitted in a new health care occupancy under 18.1.6.2.

During the survey walk-through, it was observed that not all doors in exit access corridors are provided with positive latching hardware. This deficiency could affect any patients, staff, or visitors in the immediate area by allowing smoke or fire to enter the egress corridor.

Findings include:

On 12/28/2015, accompanied by the Director of Facilities and a Maintenance Technician, the following corridor doors were observed to lack positive latching hardware as required by 19.3.6.3.2 and could be opened with minimal effort. Locations include:

1. At 2:06 PM, the north corridor doors at the OR suite
2. At 2:25 PM, the corridor door into the lower level IT suite
3. At 11:05 AM, the corridor door at the radiology suite

During the survey walk-through it was observed that exit signs did not identify a continuous path of egress in all cases. This deficiency could affect any patients, staff, or visitors in the cited area by preventing them from safely exiting the building under fire conditions.

Findings include:

On 12/28/15 at 1:10 PM, accompanied by the Director of Facilities and a Maintenance Technician, it was observed the vestibule from the sleep center into the main building did not have an exit sign as required by 19.2.10.1.

During the survey walk through, it was observed that not all exterior paths of egress to a public way are provided with surfaces that are maintainable under all weather conditions. This deficiency could affect any patients, staff, or visitors that might have to use a wheelchair or gurney to exit the building in an emergency.

Findings include:

On 12/28/2015, accompanied by the Director of Facilities and a Maintenance Technician, the following exterior doors were observed to be signed as exits but lacked a sidewalk or other maintainable surface from the door to a public way as required by 19.2.1 and 7.1.10.1.

1. At 10:00 AM, in the administrative area on the main level
2. At 1:15 PM, at the end of the corridor near the infusion unit on the main level
3. At 1:20 PM, at all exterior exit doors in the inpatient care wing

During the survey walk-through it was observed that exit access is not arranged so that exits are readily accessible at all times. This deficiency could affect the ability of patients, staff, and visitors in the smoke compartment of fire origin to safely exit the building.

Findings include:

On 12/28/2015, accompanied by the Director of Facilities and a Maintenance Technician, the following doors were observed to be signed as exit access doors but were secured with magnetic locks that require a card to unlock and which are not in compliance with 19.2.2.2.4.

1. At 2:17 PM, the exit access doors from the emergency department
2. At 3:00 PM, the cross corridor doors between the building that houses the geriatric psych wing and the main building lower level.

Adequate fire protection sprinkler coverage is not provided within the main electrical switchgear room which leaves portion of the space unprotected in the event of a fire. This deficiency could affect all patients, visitors and staff in case of a fire emergency.
On 12/28/15 at 10:30am in the company of the Maintenance Technician, the surveyor observed that 2 of the 3 upright sprinkler heads installed had been rotated 90 degrees from the horizontal position.

This STANDARD is not met as evidenced by:


Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-thru, the provider shall institute the appropriate Interim Life Safety Measures until all cited deficiencies are corrected. The provider shall include, as an attachment to the 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 measure 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 the POC progresses.

This STANDARD is not met as evidenced by:

Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-thru, the provider shall institute the appropriate Interim Life Safety Measures until all cited deficiencies are corrected. The provider shall include, as an attachment to the 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 measure 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 the POC progresses.

During the survey walk through, it was observed that not all electrical work was in compliance. This deficiency could affect any patients if a transfer switch failed.

Findings include:

On 12/28/2015, accompanied by the Facility Electrician, it was observed that the following areas are not equipped with normal power receptacles as is required by NFPA 70 1999 517-18(a) and 517-19(a).

1. At 10:35 AM, the ER rooms
2. At 10:55 AM, the OR rooms
3. At 11:20 AM, the C-section room
4. At 1:15 PM, some of the patient rooms