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Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect any patients, staff, or visitors in the building by allowing smoke or fire to pass into other occupied portions of the building.

Findings include:

On June 6, 2016 at 2:41 PM, while accompanied by the DPS, the Surveyor observed that the enclosure for the Physical Therapy Storage Room (which was observed to house fuel-fired equipment) lacks a minimum 1 hour fire resistance rating required by 38.3.2.1 and 8.4.1.2 because the ceiling of the room, whose 1 hour fire rated enclosure walls were observed to not extend to the roof deck above, lacks a 1 hour fire rating.

Based on observation during the survey walk-through, not all portions of the facility's automatic sprinkler system are properly installed and maintained. These deficiencies could affect any patients, staff, or visitors in the area of the conditions cited because the activation of sprinkler heads could be delayed.

Findings include:

On June 6, 2016 at 3:15 PM, while accompanied by the DPS, the surveyor observed that the former First Floor Surgical Department Pass-Through Room lacks a sprinkler head required by NFPA 13 1999 5-1.1.(1).

Based on observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

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 observation during the survey walk-through, not all portions of the building electrical system are installed as required. These deficiencies could affect any patients being treated in the cited areas because emergency power may not be available under certain conditions.

Findings include:

On June 7, 2016 at 8:22 AM, while accompanied by the DPS, the surveyor observed that 4 Stage I Recovery Bays, located in the First Floor PACU, lack normal power electrical receptacles required by NFPA 70 1999 517-18(a).