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Based on observation during the survey walk-through, while accompanied by facility representatives, the surveyor observed that not all exterior exit discharges are arranged or maintained to make clear the direction of egress or contained improper walking surfaces. This deficient practice could affect patients, staff and visitors by delaying emergency exiting to a public way.

Findings include:

A. On 11/30/16 at 11:00AM, while accompanied by the FM, it was observed that the exterior exit discharged at the First Floor of the Patient Financial Services was not arranged to provide a level walking surface with respect to changes in elevation, which the elevation of the floor surfaces is not maintained on both sides of the door opening, the outside step is less than the width of the exterior door. This does not comply with NFPA 101, sections 7.2.1.3.2 and 7.7.1.




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B. On 11/30/16 at 10:39 AM, while accompanied by the RDSS it was determined that on the first floor lab area contained an exit stair that discharged to an exit vestibule then to the exterior of the building. The exit discharge contained concrete pavers and gravel. The pavers were placed +/- 4-inches apart and the void was filled with loose gravel. This created an uneven walking surface and does not comply with NFPA 101, section 7.1.6.2.

Based on observation during the survey walk-thru, illumination of the exit discharge portion of the means of egress is not maintained. This deficient practice could affect patients, staff and visitors if failure to maintain illumination of the means of egress can cause delays in exiting during an emergency and preventing safe and unimpeded access to the public way.

Findings include:

On 11/30/16 while accompanied by the FM, it was observed that designated exit discharges are not being provided with exterior lighting fixtures. This does not comply with NFPA 101, sections 19.2.8, 7.8.1.4 and 7.9.1.2.

Locations observed include:

1. At 11:15 AM - First Floor, Patient Financial Services exterior exit door
2. At 11:20 AM - First Floor, Stair #1 Vestibule, designated exterior exit discharge door.

Based on observation during the survey walk-thru, exit signs are not provided to identify access to at least two exits. This deficient practice could affect patients, staff and visitors, if a failure to mark available exit access paths can compromise access to available exits when the marked route may become unavailable during a fire or smoke event.

Findings include:

A. On 11/30/16 at 10:45 AM while accompanied by the FM, it was observed that only one path of exit access in the corridor of the Cardio Pulmonary Rehab was identified by exit signage. The same corridor lacked a readily visible exit sign to reach an exit that is apparent to the occupants near the EVS and by the Regional Medical Director Care Management. This does not comply with NFPA 101 sections, 19.2.10.1, 7.10.

B. On 11/30/16 at 10:50 AM, while accompanied by the FM in the Health Information, it was observed that access to exit is not marked by approved visible signs where way to reach the exit is not readily apparent to the occupants. This does not comply with NFPA 101, section 19.2.10.1.



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C. On 11/30/16 at 10:07 AM, while accompanied by the RDSS it was determined that on the First Floor, Pharmacy Corridor an " EXIT " sign in the Health Information, it was observed that access to exit is not marked by approved visible signs where way to reach the exit is not readily apparent to the occupants. This does not comply with NFPA 101, section 19.2.10.1.

Based on direct observation not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This deficient practice may affect patients, staff and visitors on the upper floors from a safe means of egress to a discharge during a fire/smoke event.

Findings include:

On 11/30/16 at 2:30 PM, while accompanied by the FM, a ductwork was observed to penetrate the designated 2-hour fire rated exit passageway of the Exit Stair #1 enclosure, near the EVS Room, which lacked a fire damper. This does not comply with NFPA 101 19.3.1.2 and 7.1.3.2.1 (11).

Based on direct observations of hazardous areas and interviews, the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

A. On 11/30/16 at 11:30 AM, while accompanied by FM, it was determined that the door to the Clean Storage Room, in the Ambulatory Wing - Second Floor, was not labeled and not maintained. This does not comply with NFPA 101, section 8.3.3.2.



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B. On 11/30/16 at 10:06 AM, while accompanied by the RDSS it was determined that on the first floor pharmacy corridor contained 2-hr fire rated double doors. The inactive door leaf was installed with a lower vertical rod but the required floor receives was not installed. This does not comply with NFPA 80, section 4.1.3.1.

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 11/30/16 at 10:40 AM, while accompanied by the FM, it was observed that the Stair #4 T1040 First Floor landing lacked sprinkler protection to comply with NFPA 101 19.3.5.3 and NFPA 13.

Based on observations and interviews the facility failed to provide exit access corridors properly separated from use areas as required. This deficiency could affect any patients, staff, or visitors in the area by compromising the protection offered by the egress corridors.

Findings include:

On 11/30/16 AM, while accompanied by the RDSS, it was determined that on the Second Floor-main contained an ambulatory surgery waiting area that was open to the corridor and was not installed with a smoke detector. The door to the waiting area is installed with a door closer but has a lock open function and will not release until staff release the door. This does not comply with NFPA 101, section 19.3.6.1.

Based on observation the facility failed to provide properly operating doors within the means of egress. This deficiency could affect all patients in the locations as well as any staff and visitors present, by compromising a person's access to an exit.

Findings include:

On 11/30/16 at 11:05 AM, while accompanied by the FM, the smoke barrier pair of doors to the OR Suite on the Second Floor was observed with an exit sign above the doors to have a magnetic locking device, which does not have the delayed egress feature provision. This does not comply with NFPA 101, sections 7.2.1.6. and 7.2.

Based on direct observation the facility failed to install a compliant Category 1 Medical Gas System. This deficient practice could result in the failure / response during a fire event, which may affect patients, staff and visitors.
On 11/30/2016 at 9:00 AM, in the company of the GL, it was observed that zone valves are installed within the same space for the outlets/inlets they control and not placed on a interveneing wall at the following locations. (NFPA 99, 2012, 5.1.4.8)
1. Second Floor Surgical Heart Unit
2. Second Floor ICU

Based on observations and interviews the facility failed to provide a compliant electrical system. This deficient practice could affect patients, staff and visitors during a power outage if the electrical system did function properly.
Findings include:
A. On 11/29/16 at 1:15 PM, while accompanied by the HE, it was observed that the penthouse elevator equipment rooms were not equipped with overcurrent protection served from the life safety branch of emergency power for the elevator cab lighting, controls, communication and signal systems in accordance with the 2012 Edition of NFPA-99, Section 6.4.2.2.3.2, and the 2011 Edition of NFPA-70, Section 620.22.
B. On 11/30/16 at 9:45 AM, while accompanied by the HE, it was observed that critical panel CR1-F was serving elevators 6 and 7. This is not in compliance with the 2012 Edition of NFPA-99, Section 6.4.2.2.4, and Section 6.4.2.2.5.4.

Based on observations and interview, the facility failed to provide a compliant electrical system. This deficient practice could affect critical care patients, patients undergoing procedures and staff during a power outage if the electrical system did not provide the proper power requirements.

Findings include:

On 11/29/16 at 2:45 PM, while accompanied by the HE, it was observed that the following locations were not equipped with normal and critical receptacles in accordance with the 2012 Edition of NFPA-99, Section 6.3.2.2.1.2.
1. ICU rooms
2. SICU rooms
3. Operating rooms
4. Cath Lab

Based on observation during the survey walk-through, while accompanied by facility representatives, the surveyor observed that not all exterior exit discharges are arranged or maintained to make clear the direction of egress or contained improper walking surfaces. This deficient practice could affect patients, staff and visitors by delaying emergency exiting to a public way.

Findings include:

A. On 11/30/16 at 11:00AM, while accompanied by the FM, it was observed that the exterior exit discharged at the First Floor of the Patient Financial Services was not arranged to provide a level walking surface with respect to changes in elevation, which the elevation of the floor surfaces is not maintained on both sides of the door opening, the outside step is less than the width of the exterior door. This does not comply with NFPA 101, sections 7.2.1.3.2 and 7.7.1.




31586

B. On 11/30/16 at 10:39 AM, while accompanied by the RDSS it was determined that on the first floor lab area contained an exit stair that discharged to an exit vestibule then to the exterior of the building. The exit discharge contained concrete pavers and gravel. The pavers were placed +/- 4-inches apart and the void was filled with loose gravel. This created an uneven walking surface and does not comply with NFPA 101, section 7.1.6.2.

Based on observation during the survey walk-thru, illumination of the exit discharge portion of the means of egress is not maintained. This deficient practice could affect patients, staff and visitors if failure to maintain illumination of the means of egress can cause delays in exiting during an emergency and preventing safe and unimpeded access to the public way.

Findings include:

On 11/30/16 while accompanied by the FM, it was observed that designated exit discharges are not being provided with exterior lighting fixtures. This does not comply with NFPA 101, sections 19.2.8, 7.8.1.4 and 7.9.1.2.

Locations observed include:

1. At 11:15 AM - First Floor, Patient Financial Services exterior exit door
2. At 11:20 AM - First Floor, Stair #1 Vestibule, designated exterior exit discharge door.

Based on observation during the survey walk-thru, exit signs are not provided to identify access to at least two exits. This deficient practice could affect patients, staff and visitors, if a failure to mark available exit access paths can compromise access to available exits when the marked route may become unavailable during a fire or smoke event.

Findings include:

A. On 11/30/16 at 10:45 AM while accompanied by the FM, it was observed that only one path of exit access in the corridor of the Cardio Pulmonary Rehab was identified by exit signage. The same corridor lacked a readily visible exit sign to reach an exit that is apparent to the occupants near the EVS and by the Regional Medical Director Care Management. This does not comply with NFPA 101 sections, 19.2.10.1, 7.10.

B. On 11/30/16 at 10:50 AM, while accompanied by the FM in the Health Information, it was observed that access to exit is not marked by approved visible signs where way to reach the exit is not readily apparent to the occupants. This does not comply with NFPA 101, section 19.2.10.1.



31586

C. On 11/30/16 at 10:07 AM, while accompanied by the RDSS it was determined that on the First Floor, Pharmacy Corridor an " EXIT " sign in the Health Information, it was observed that access to exit is not marked by approved visible signs where way to reach the exit is not readily apparent to the occupants. This does not comply with NFPA 101, section 19.2.10.1.

Based on direct observation not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This deficient practice may affect patients, staff and visitors on the upper floors from a safe means of egress to a discharge during a fire/smoke event.

Findings include:

On 11/30/16 at 2:30 PM, while accompanied by the FM, a ductwork was observed to penetrate the designated 2-hour fire rated exit passageway of the Exit Stair #1 enclosure, near the EVS Room, which lacked a fire damper. This does not comply with NFPA 101 19.3.1.2 and 7.1.3.2.1 (11).

Based on direct observations of hazardous areas and interviews, the facility failed to provide properly operating latching and self-closing door hardware that provides separation between hazardous areas and exit access corridors. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

A. On 11/30/16 at 11:30 AM, while accompanied by FM, it was determined that the door to the Clean Storage Room, in the Ambulatory Wing - Second Floor, was not labeled and not maintained. This does not comply with NFPA 101, section 8.3.3.2.



31586

B. On 11/30/16 at 10:06 AM, while accompanied by the RDSS it was determined that on the first floor pharmacy corridor contained 2-hr fire rated double doors. The inactive door leaf was installed with a lower vertical rod but the required floor receives was not installed. This does not comply with NFPA 80, section 4.1.3.1.

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 11/30/16 at 10:40 AM, while accompanied by the FM, it was observed that the Stair #4 T1040 First Floor landing lacked sprinkler protection to comply with NFPA 101 19.3.5.3 and NFPA 13.

Based on observations and interviews the facility failed to provide exit access corridors properly separated from use areas as required. This deficiency could affect any patients, staff, or visitors in the area by compromising the protection offered by the egress corridors.

Findings include:

On 11/30/16 AM, while accompanied by the RDSS, it was determined that on the Second Floor-main contained an ambulatory surgery waiting area that was open to the corridor and was not installed with a smoke detector. The door to the waiting area is installed with a door closer but has a lock open function and will not release until staff release the door. This does not comply with NFPA 101, section 19.3.6.1.

Based on observation the facility failed to provide properly operating doors within the means of egress. This deficiency could affect all patients in the locations as well as any staff and visitors present, by compromising a person's access to an exit.

Findings include:

On 11/30/16 at 11:05 AM, while accompanied by the FM, the smoke barrier pair of doors to the OR Suite on the Second Floor was observed with an exit sign above the doors to have a magnetic locking device, which does not have the delayed egress feature provision. This does not comply with NFPA 101, sections 7.2.1.6. and 7.2.

Based on direct observation the facility failed to install a compliant Category 1 Medical Gas System. This deficient practice could result in the failure / response during a fire event, which may affect patients, staff and visitors.
On 11/30/2016 at 9:00 AM, in the company of the GL, it was observed that zone valves are installed within the same space for the outlets/inlets they control and not placed on a interveneing wall at the following locations. (NFPA 99, 2012, 5.1.4.8)
1. Second Floor Surgical Heart Unit
2. Second Floor ICU

Based on observations and interviews the facility failed to provide a compliant electrical system. This deficient practice could affect patients, staff and visitors during a power outage if the electrical system did function properly.
Findings include:
A. On 11/29/16 at 1:15 PM, while accompanied by the HE, it was observed that the penthouse elevator equipment rooms were not equipped with overcurrent protection served from the life safety branch of emergency power for the elevator cab lighting, controls, communication and signal systems in accordance with the 2012 Edition of NFPA-99, Section 6.4.2.2.3.2, and the 2011 Edition of NFPA-70, Section 620.22.
B. On 11/30/16 at 9:45 AM, while accompanied by the HE, it was observed that critical panel CR1-F was serving elevators 6 and 7. This is not in compliance with the 2012 Edition of NFPA-99, Section 6.4.2.2.4, and Section 6.4.2.2.5.4.

Based on observations and interview, the facility failed to provide a compliant electrical system. This deficient practice could affect critical care patients, patients undergoing procedures and staff during a power outage if the electrical system did not provide the proper power requirements.

Findings include:

On 11/29/16 at 2:45 PM, while accompanied by the HE, it was observed that the following locations were not equipped with normal and critical receptacles in accordance with the 2012 Edition of NFPA-99, Section 6.3.2.2.1.2.
1. ICU rooms
2. SICU rooms
3. Operating rooms
4. Cath Lab