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Based on observation, interview, and a review of facility flame spread documents, the facility did not provide corridor finishes with rated wall finish materials. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 6 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 5, 2011 at 2:30 PM surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the dinning room, that the facility could not confirm the wall had an appropriate rating . The corridor wall was finished with wall paper depicting scenic views. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 4, 2011 at 12:00 pm surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the room 221, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated wall construction. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 5, 2011 at 11:00 am surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the main stairway, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because gun holding boxes were cut into the cinder block. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On April 5, 2011 at 1:15 pm surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the soiled utility room, that a penetration was not sealed according to approved listed testing agency designs. The deficiency included a sprinkler pipe. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

2. On April 5, 2011 at 1:30 pm surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the closet of patient storage, that a penetration was not sealed according to approved listed testing agency designs. The deficiency included a sprinkler pipe. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

3. On April 5, 2011 at 3:00 pm surveyor #12187 observed in the basement smoke compartment on the basement floor in the business record storage room, that a penetration was not sealed according to approved listed testing agency designs. The deficiency included a three inch diameter steel pipe that ran along the cinder block wall for 6 feet, removing about half of the cinder block material for that distance. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide egress paths at all times with door hardware that operated with a single release motion. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 4, 2011 at 12:12 PM surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the med room , that the door release hardware required more than a single motion to release the door for exiting. The hardware included a keyed dead bolt and standard passage hardware. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide and maintain emergency illumination of the generator area for at least 90 minutes after a power failure with an emergency battery light at the emergency generator. This deficiency occurred in 5 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 5, 2011 at 11:30 am surveyor #12187 observed that a battery-operated emergency light was not installed in the interior emergency generator location. This observed situation was not compliant with NFPA 101 (2000 edition), 7.9.2.3, and NFPA 110 (1999 edition), 5-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The facility did not provide a sprinkler system with all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 5, 2011 at 2:00 PM surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the nurse station, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The area above the nurse station has 2 X 4 wood studs concealed in the soffit. Sprinklers are required because smoke dampers are not located in ducts that pass through smoke barrier walls. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A. The required damper maintenance was not done and neutral airflow between the corridor and rooms was not maintained. This deficiency occurred in 5 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On April 4, 2011 at 4:00 PM surveyor #12187 observed that during a review of documents it was discovered that all required maintenance procedures were not performed.
Dampers were missing at the following locatations:
A) the penthouse air handling unit, AC #2, which feeds the hospital wing, had main supply and return ducts that did not have fire dampers at the bottom of their respective masonry shafts that extended from the penthouse, through the 4th & 2nd levels to a crawl space located below the 2nd level.
B) approximately 20 duct penetrations through the level 2 floor did not have fire dampers. The 5 " x12 " ducts in the crawl space passed through the level 2 floor, without dampers, to feed the floor mounted ventilation units on that floor. These ducts exceeded the maximum size permitted by the exception in section 903 to not have fire dampers.
C) about 6-8 supply and return ducts did not have fire dampers where they penetrated the penthouse and 4th level floors to serve the overhead ventilation grills on the 2nd level in the center core of the hospital space located below the footprint of the penthouse.
This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1; 9.2.1; and NFPA 90A (1999 edition), 3-4.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

2. On April 4, 2011 at 11:30 am surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the room 216, negative pressure room, that airflow between the corridor and this room was not neutral. The air from the room is required to be exhausted only when the room is being used as a negative pressure room. When the room is a negative pressure room, both the exhaust air and return air are operating, greatly increasing the amount of air being taken from the corridor. The additional air being taken from the corridor is using the corridor as a supply air system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not maintain an egress path that was free of highly flammable furnishings/decoration, as with non-combustible decorations. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 4 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 4, 2011 at 1:45 PM surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the gym stage, that decorations made with combustible materials were used. The items could not be confirmed as being flame-retardant. The decorations included six Christmas trees. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.2 thru 19.7.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 4, 2011 at 12:15 PM surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the med room, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. There was two 20 gallon containers of mixed paper and confidential waste material next to each other in the meds room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with generator with a remote stop. This deficiency occurred in 5 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 5, 2011 at 11:35 am surveyor #12187 observed that the emergency generator was not provided with a remote stop switch outside of the generator enclosure. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation, interview, and a review of facility flame spread documents, the facility did not provide corridor finishes with rated wall finish materials. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 6 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 5, 2011 at 2:30 PM surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the dinning room, that the facility could not confirm the wall had an appropriate rating . The corridor wall was finished with wall paper depicting scenic views. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 4, 2011 at 12:00 pm surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the room 221, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated wall construction. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 5, 2011 at 11:00 am surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the main stairway, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because gun holding boxes were cut into the cinder block. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On April 5, 2011 at 1:15 pm surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the soiled utility room, that a penetration was not sealed according to approved listed testing agency designs. The deficiency included a sprinkler pipe. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

2. On April 5, 2011 at 1:30 pm surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the closet of patient storage, that a penetration was not sealed according to approved listed testing agency designs. The deficiency included a sprinkler pipe. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

3. On April 5, 2011 at 3:00 pm surveyor #12187 observed in the basement smoke compartment on the basement floor in the business record storage room, that a penetration was not sealed according to approved listed testing agency designs. The deficiency included a three inch diameter steel pipe that ran along the cinder block wall for 6 feet, removing about half of the cinder block material for that distance. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide egress paths at all times with door hardware that operated with a single release motion. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 4, 2011 at 12:12 PM surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the med room , that the door release hardware required more than a single motion to release the door for exiting. The hardware included a keyed dead bolt and standard passage hardware. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide and maintain emergency illumination of the generator area for at least 90 minutes after a power failure with an emergency battery light at the emergency generator. This deficiency occurred in 5 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 5, 2011 at 11:30 am surveyor #12187 observed that a battery-operated emergency light was not installed in the interior emergency generator location. This observed situation was not compliant with NFPA 101 (2000 edition), 7.9.2.3, and NFPA 110 (1999 edition), 5-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The facility did not provide a sprinkler system with all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 5, 2011 at 2:00 PM surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the nurse station, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The area above the nurse station has 2 X 4 wood studs concealed in the soffit. Sprinklers are required because smoke dampers are not located in ducts that pass through smoke barrier walls. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A. The required damper maintenance was not done and neutral airflow between the corridor and rooms was not maintained. This deficiency occurred in 5 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On April 4, 2011 at 4:00 PM surveyor #12187 observed that during a review of documents it was discovered that all required maintenance procedures were not performed.
Dampers were missing at the following locatations:
A) the penthouse air handling unit, AC #2, which feeds the hospital wing, had main supply and return ducts that did not have fire dampers at the bottom of their respective masonry shafts that extended from the penthouse, through the 4th & 2nd levels to a crawl space located below the 2nd level.
B) approximately 20 duct penetrations through the level 2 floor did not have fire dampers. The 5 " x12 " ducts in the crawl space passed through the level 2 floor, without dampers, to feed the floor mounted ventilation units on that floor. These ducts exceeded the maximum size permitted by the exception in section 903 to not have fire dampers.
C) about 6-8 supply and return ducts did not have fire dampers where they penetrated the penthouse and 4th level floors to serve the overhead ventilation grills on the 2nd level in the center core of the hospital space located below the footprint of the penthouse.
This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1; 9.2.1; and NFPA 90A (1999 edition), 3-4.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

2. On April 4, 2011 at 11:30 am surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the room 216, negative pressure room, that airflow between the corridor and this room was not neutral. The air from the room is required to be exhausted only when the room is being used as a negative pressure room. When the room is a negative pressure room, both the exhaust air and return air are operating, greatly increasing the amount of air being taken from the corridor. The additional air being taken from the corridor is using the corridor as a supply air system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not maintain an egress path that was free of highly flammable furnishings/decoration, as with non-combustible decorations. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 4 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 4, 2011 at 1:45 PM surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the gym stage, that decorations made with combustible materials were used. The items could not be confirmed as being flame-retardant. The decorations included six Christmas trees. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.2 thru 19.7.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 4, 2011 at 12:15 PM surveyor #12187 observed in the main hospital smoke compartment on the 1st floor in the med room, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. There was two 20 gallon containers of mixed paper and confidential waste material next to each other in the meds room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with generator with a remote stop. This deficiency occurred in 5 of the 5 smoke compartments, and had the potential to affect 14 of the 16 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On April 5, 2011 at 11:35 am surveyor #12187 observed that the emergency generator was not provided with a remote stop switch outside of the generator enclosure. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Maintenance Supervisor).