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Based on observations, staff interview, and review of the facility evacuation plans, the facility failed to ensure two exits that were not readily apparent were equipped with exit signs. This involved the 9th floor dialysis unit and the ground floor by the emergency department. This could potentially affect all patients, staff, and visitors in the building. The facility has a total capacity of 104 beds. The total patient census on the first day of survey was 49 patients.

Findings include:

A tour of the facility was conducted on 03/19/14, between 8:30 AM and 10:45 AM, with Staff Y and with host hospital Staff W and V. This tour revealed the ninth floor lacked a two hour fire separation between this facility and the host hospital therapy unit and acute in-patient dialysis unit. A tour of the dialysis unit revealed one clearly designated exit; however, the second exit from the unit opened directly into the north hallway. This exit was not listed on the written evacuation plan, and lacked an exit sign to alert staff, patients, and visitors to this exit. The surveyor was unaware of the exit during tour until Staff W stated there was another exit in the unit, referring to this area as an exit.

Stair D's exit discharge on the ground floor led to a set of double doors by the emergency department waiting room. Located in this same hallway area were two unlocked bathrooms located by an unmanned reception desk. Upon approaching this area, a set of two inner glass doors led to another set of exit doors. The exit sign was displayed over the outer set of door; however, could not be viewed in the hallway leading to the double glass doors until being in close proximity of the double glass doors.

Staff Y, W, and V verified these aforementioned observations during the tour.

Based on observations and staff interviews, the facility failed to ensure smoke detectors were located greater than 36 inches from air supply diffusers, in accordance with the code at 9.6.1.4 and NFPA 72, 2-3.5.1. This affected 20 smoke detectors on the ninth floor, and could affect all twelve patients in the facility. The total census on the first day of survey was 49 patients.

Findings include:

A tour was conducted on 03/19/14 between 8:30 AM and 9:14 AM on the ninth floor. The entire floor was surveyed for life safety code due to a lack of two hour fire resistant barrier between this facility and the host hospital. The tour was conducted with Staff Y and with Staff W and V (both host hospital staff).

Observations on the ninth floor revealed smoke detectors were located within 1-2 feet of air supply diffusers in the following locations:
Room 901
Room 902
Room 903
Room 905
Room 906
Room 908
Room 909
Storage room SPB9-119
In the north hall outside dialysis storage room
In the corridor by the smoke barrier near Stair D.

These smoke detector locations were verified with Staff Y, W, and V during the tour. Staff W stated the host hospital was aware of the smoke detector locations, and had a plan to move the detectors. Staff W stated the smoke detectors did need to be relocated farther away from the air supply diffusers.

Based on staff interview, observations, and review of the kitchen hood (ansul) system, the facility failed to ensure the ansul was inspected at least every 6 months in accordance with NFPA 96, 9-2. This could potentially affect all patients, staff, and visitors in the facility. The facility has a capacity of 104 beds. The total census on the first day of survey was 49 patients.

Findings include:

A tour was conducted on 03/20/14 between 9:58 AM and 11:12 PM with Staff Y and host hospital Staff T and U. A tour of the kitchen revealed a wet chemical hood system which contained an inspection tag dated 08/2013.

Interview with host hospital Staff T and U, and review of the kitchen ansul inspections revealed the last completed ansul inspection was 08/2013, over 6 months ago. Staff U stated the ansul should have been inspected by the outside service company in February 2014.

Based on staff interviews, observations, and review of the medical gas inspection report, the facility failed to take action to correct deficient findings in the medical gas piped-in oxygen system on the ninth floor. This could potentially affect all patients, staff, and visitors in the facility. The facility has a total capacity of 104 beds. The total patient census on the first day of survey was 49 patients.

Findings include:

A tour of the facility was conducted on 03/19/14, between 8:30 AM and 10:45 AM, with Staff Y and with host hospital Staff W and V. During the tour, the facility was observed with a large open area which contained 6 beds and two patients. According to Staff Y, this area was used by the facility for patient care, and was leased from the host hospital. Staff Y stated this area previously had been a post anesthesia care unit (PACU). During tour, two patients in beds were observed in this large open area. A medical gas shut off panel was observed on the wall inside this room by the nurses' station.

A review of the last inspection, dated 03/06/13, by the outside medical gas company, revealed the following unacceptable deficient findings in this facility:

1) B Zone 1 for Rooms 901-909 required gauges on the medical gas system.
2) B Zone 2 PACU beds 11-20 and Holding room required gauges on the medical gas system.
3) B Zone 2 PACU beds 11-20 zone valve box is located in the same room as outlets, with no wall in-between.

Interviews with host hospital Staff W, at 11:30 AM, revealed the host hospital was aware of the unacceptable results and have made no changes to the system to correct the identified deficiencies as of current survey date. Interview with Staff Y at that same time revealed there had been no changes to this system since the medical gas company's findings in March 2013.

Staff Y stated the facility hired a consultant to perform a life safety code inspection at this facility. Staff Y provided a copy of the consultant report, dated 11/07/13. A review of this report revealed the following documentation by the consultant:
"NFPA 99 requires an intervening wall between the oxygen shut-off valves and the oxygen outlets. The open bed unit lacks an intervening wall between the shut-off valve and the open beds. A PFI (plan for improvement) was entered on the SOC (statement of conditions) to correct this issue from my visit in 2011 and the due date is in 2016."

Based on observations, staff interviews, and review of generator logs, the facility failed to ensure the generators were inspected weekly in accordance with NFPA 110, 6-4.1, and were unaware if the automatic transfer switch engaged, allowing the generators to start within 10 seconds in accordance with the NFPA 110, 6-4.5. This could potentially affect all patients, staff, and visitors in the building. The facility has a total capacity of 104 beds. The total patient census on the first day of survey was 49 patients.

Findings include:

A tour was conducted on 03/20/14 between 9:58 AM and 11:12 PM with Staff Y and host hospital Staff T and U. A review was conducted of the generator logs between 8:00 AM and 9:30 AM on the same day with these same staff.

During tour, the facility was observed with two generators. According to host hospital Staff U, these generators serviced the third floor where the facility is located. A clipboard in the generator room revealed weekly inspections were being conducted on the generators. However, this inspection log only contained a date and the initials of the staff who performed the inspections. The logs were silent to the areas which were inspected.

A review of monthly generator logs revealed the logs were silent to the amount of time it took for the automatic transfer switch to work to start the generators.

These observations and generator logs were verified by all three staff members during the tour and documentation review.