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Based on observation, staff interviews, and review of maintenance records between April 6 and April 9, 2015, and during a verification visit on May 27, 2015 the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings:

The facility was found to contain the following deficiencies.
K 11: facility did not provide a common separation wall with sealed wall penetrations
K 12: unprotected construction type for the building;
K 25: improperly constructed and maintained smoke barriers;
K 29: the facility did not enclose hazardous rooms with closers on all doors, rated doors, and doors held-open with the required safe guards.
K 38: egress paths were not clear at all times, doors were lockable in the egress path, and not sufficient ceiling height;
K 46: the facility did not provide and maintain emergency illumination of the interior means of egress for at least 90 minutes after a power failure.
K 52: the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with compliant fire alarm testing.
K 70: provided portable space heating devices that did comply with code requirements
K 76: improper distance between oxygen storage and combustibles and tanks not restrained;
K 145: the facility did not provide a proper Type I emergency electrical system.
K 147: deficiencies in the electrical systems.

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interviews and review of maintenance records, the facility did not construct, install and maintain a proper ventilation and temperature control system in pharmaceutical, food preparation, and other appropriate areas. The facility did not have and a ventilation system that was installed and maintained in accordance with manufacturer recommendations. This deficiency occurred in 2 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

Findings:

On April 6, 2015 at 4:00 pm, and during a verification visit on May 27, 2015, observation revealed on the 1st floor in the patient bathrooms, that the ventilation to the space could not be confirmed to be compliant with acceptable standards. During the winter when the temperature is below 24 F, the make-up air for the patient bathrooms shuts down ('trips out') because of the cold temperature and will not stay on. This has been the case for at least the past two winters (13-14, and 14-15). The supply air then probably comes from either the corridor or through the window cracks in the patient rooms or a combination of the two Using window cracks or the corridor as your supply air is prohibited. It is required to have 10 exhaust air changes, and the air be neutral to the corridor per Guidelines for Design and Construction of Health Care Facilities The Facility Guidelines Institute 2010 (FGI Guidelines) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) Standard 170.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff D (Physical Plant Director).

Based on observation, staff interviews, and review of maintenance records between April 6 and April 9, 2015, and during a verification visit on May 27, 2015 the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings:

The facility was found to contain the following deficiencies.
K 11: facility did not provide a common separation wall with sealed wall penetrations
K 12: unprotected construction type for the building;
K 25: improperly constructed and maintained smoke barriers;
K 29: the facility did not enclose hazardous rooms with closers on all doors, rated doors, and doors held-open with the required safe guards.
K 38: egress paths were not clear at all times, doors were lockable in the egress path, and not sufficient ceiling height;
K 46: the facility did not provide and maintain emergency illumination of the interior means of egress for at least 90 minutes after a power failure.
K 52: the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with compliant fire alarm testing.
K 70: provided portable space heating devices that did comply with code requirements
K 76: improper distance between oxygen storage and combustibles and tanks not restrained;
K 145: the facility did not provide a proper Type I emergency electrical system.
K 147: deficiencies in the electrical systems.

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.