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Based on observations the facility failed to provide a building with an acceptable construction type. This deficient practice could affect patients, staff and visitors if a fire in the deficient area were to compromise the buildings structural integrity during a fire emergency.

Findings include:

On May 17, 2017 while accompanied by the POD, the surveyor observed various beams that are not protected with a fire rated assembly to comply with Table 19.1.6.1 and NFPA 220 2012 Ed. Table 4.1.1. Example locations are as follows:

1. At 8:48 am 4th floor West wing, corridor area adjacent to Room #414 contains an above ceiling support beam which lacks fireproofing on the bottom flange.

2. At 10:45 am 2nd floor Electrical room located adjacent to the elevators, contains a support beam located above the electrical panels L2 sec 1 and L2 sec 2 which lacks fireproofing on the bottom flange.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. 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 identifying the path to an available exit from the building.

The finding is:

On May 16, 2017 at 2:50pm while accompanied by the POD only one path of exit access was observed to be identified by exit signage which does not comply with 19.2.5.4. Location observed: 1st floor corridor adjacent to Tray Make up and Dining room looking toward the south end of the corridor.

Based upon observation, vertical openings are not constructed and maintained to provide separation of floor levels in accordance with requirements. Failure to protect vertical openings can permit the effects of a fire/smoke event to expose and compromise the safety of occupants on other floor levels.

The finding is:

On May 17, 2017 at 9:30am while accompanied by the POD it was observed that the 4th floor Art Therapy room contained a hole through the gypsum board ceiling where a camera had been removed. The remaining opening does not comply with 19.3.1 and 8.3.5.1 for the enclosure of a vertical through floor/roof opening.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's exit access corridors.

Findings include:

On May 17, 2017 at 2:10pm while accompanied by the POD the Medical Records room deemed as a hazardous area on the facility's Life Safety floor plans was observed to not be separated from non hazardous areas/rooms (offices and corridors). Location observed: rooms, directly adjacent to the Medical Records room does not meet the separation requirements for doors to comply with 8.4.3 and 7.2.1.8.1.

Based on observation during the survey walk through the facility failed to correctly install cooking equipment. This deficient practice could result in the uncontrolled spread of fire and products of combustion during kitchen cooking operations, which may affect patients, staff and visitors.

The finding is:

On 5/16/17 at 2:50/PM accompanied by the POD, it was observed in the kitchen that the deep-fat fryer is installed less than 16 inches for the adjacent surface flames of the range/cooktop. NFPA 96, 2008, 12.1.2.4.

Based on observation during the survey walk-thru, smoke detection devices are improperly installed. This deficient practice could affect patients, staff and visitors if the components are not installed in accordance with Code requirements, and the system could not provide effective warning to permit immediate response to a fire/smoke event.

The finding is:

On May 17, 2017 at 8:55am, while accompanied by the POD, the surveyor observed a smoke detector that is installed too close to the supply air / exhaust diffuser which does not comply NFPA 72-2010, 17.7.3.2.1. Location observed: 4th Floor aisle near the Quiet Room.

Based upon observation, corridor walls are not constructed and maintained to provide a smoke tight separation. Failure to protect means of egress corridors can permit the effects of a fire/smoke event to expose and compromise the safe movement of occupants.

Findings include:

On May 17, 2017 at 1:00pm while accompanied by the POD an open junction box was observed recessed into the corridor wall which does not comply with 19.3.6.2.2 for a smoke tight enclosure. Location observed: 4th floor West wing corridor wall above the ceiling adjacent to Quiet room #2 at the wall mounted phone.