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Based on observations the facility failed to provide the required one-half (?) hour fire resistance rating for smoke barrier walls located in an existing fully sprinkled facility.

Smoke barriers shall be provided to divide every story used for sleeping rooms into not less than two (2) smoke compartments. Any required smoke barrier shall be constructed with a fire resistance rating of not less than ? hour. NFPA 101, 19.3.7.3.

Findings include:

While inspecting smoke compartmentalization on 05-12-11at 11:30 a.m., the surveyor observed the outpatient smoke barrier wall located between the Emergency Department (E.D.) and the surgery unit incomplete. The smoke barrier wall was observed with 80 to 100 feet of wall unfinished. The wall was constructed to the lay-in ceiling then terminated, leaving six (6) feet of wall from the lay in ceiling to the roof deck open. The surveyor also observed numerous unsealed penetrations located throughout the cafeteria smoke barrier wall. These penetrations were observed ranging in size from an ink pen to one (1) foot in diameter.

These deficient practices have the potential of affecting the entire facility. The Administrator and Maintenance Director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required smoke resistive construction in hazardous areas.

Findings include:

While inspecting hazardous areas on 5-12-11 at 11:15 a.m., the surveyor observed the following hazardous areas without the required smoke resistive construction and self closing hardware on opening protective:
1. Med air room was observed with unsealed penetrations throughout.
2. Nitrous storage/storage room was observed with unsealed penetrations throughout.
3. Transformer electrical room/transfer switch room was observed with unsealed penetrations throughout.
4. Exterior boiler room fire wall was observed with unsealed penetrations throughout.

These deficient practices have the potential of affecting four (4) of four (4) smoke compartments. The Administrator and the Maintenance Director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide a clear and unobstructed exit access corridor.

Findings include:

While inspecting the means of egress on 5-12-11 at 1:00 p.m., the surveyor observed the outpatient registration corridor obstructed from the allowable eight (8) feet in clear width to five (5) feet. The obstructions were three (3) feet wide by five (5) feet tall barriers that were installed at the outpatient registration.

This deficient practice has the potential of affecting one (1) of four (4) smoke compartments. The Administrator and the Maintenance Director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required audible visual fire alarm notification devices.

Occupant notification shall provide signal notification to alert occupants of fire or other emergencies. Notification shall be provided by audible and visible signals. NFPA 101, 9.6.3.

Findings include:

While inspecting fire alarm components on 5-12-11at 9:45 a.m., the surveyor observed the C.T. Hall, the X-ray Hall, Medical Records Hall, and the front lobby without audible visual notification devices. When alarm system was initiated, these areas did not have any notification.

This deficient practice has the potential of affecting two (2) of four (4) smoke compartments. The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide a supervised automatic sprinkler system with flow switches that are electrically interconnected to the buildings fire alarm system.

Findings include:

While inspecting the sprinkler system on 5-12-11 at 1:50 p.m., the surveyor observed the fire alarm system was not monitoring the sprinkler system. At 1:45 p.m., the surveyor and the Maintenance Director performed a flow test at the inspectors test valve located in the Emergency Department (ED); after three (3) minutes of water flow it was determined the flow switch is not being monitored.

This deficient practice has the potential of affecting four (4) of four (4) smoke compartments. The Administrator and the Maintenance Director were notified during the survey and in the exit conference.

Based on observations, the facility failed to properly install and protect all of the generator ' s required components.

Findings Include:

On May 12, 2011 at appx. 11:30 a.m., the maintenance person and surveyor found that the facility lacked the required task illumination light serving the generator set location. An interview with the maintenance person revealed that the facility was unaware of the requirement.

This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey as well as the exit conference.

Based on observations the facility failed to provide the required one-half (?) hour fire resistance rating for smoke barrier walls located in an existing fully sprinkled facility.

Smoke barriers shall be provided to divide every story used for sleeping rooms into not less than two (2) smoke compartments. Any required smoke barrier shall be constructed with a fire resistance rating of not less than ? hour. NFPA 101, 19.3.7.3.

Findings include:

While inspecting smoke compartmentalization on 05-12-11at 11:30 a.m., the surveyor observed the outpatient smoke barrier wall located between the Emergency Department (E.D.) and the surgery unit incomplete. The smoke barrier wall was observed with 80 to 100 feet of wall unfinished. The wall was constructed to the lay-in ceiling then terminated, leaving six (6) feet of wall from the lay in ceiling to the roof deck open. The surveyor also observed numerous unsealed penetrations located throughout the cafeteria smoke barrier wall. These penetrations were observed ranging in size from an ink pen to one (1) foot in diameter.

These deficient practices have the potential of affecting the entire facility. The Administrator and Maintenance Director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required smoke resistive construction in hazardous areas.

Findings include:

While inspecting hazardous areas on 5-12-11 at 11:15 a.m., the surveyor observed the following hazardous areas without the required smoke resistive construction and self closing hardware on opening protective:
1. Med air room was observed with unsealed penetrations throughout.
2. Nitrous storage/storage room was observed with unsealed penetrations throughout.
3. Transformer electrical room/transfer switch room was observed with unsealed penetrations throughout.
4. Exterior boiler room fire wall was observed with unsealed penetrations throughout.

These deficient practices have the potential of affecting four (4) of four (4) smoke compartments. The Administrator and the Maintenance Director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide a clear and unobstructed exit access corridor.

Findings include:

While inspecting the means of egress on 5-12-11 at 1:00 p.m., the surveyor observed the outpatient registration corridor obstructed from the allowable eight (8) feet in clear width to five (5) feet. The obstructions were three (3) feet wide by five (5) feet tall barriers that were installed at the outpatient registration.

This deficient practice has the potential of affecting one (1) of four (4) smoke compartments. The Administrator and the Maintenance Director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required audible visual fire alarm notification devices.

Occupant notification shall provide signal notification to alert occupants of fire or other emergencies. Notification shall be provided by audible and visible signals. NFPA 101, 9.6.3.

Findings include:

While inspecting fire alarm components on 5-12-11at 9:45 a.m., the surveyor observed the C.T. Hall, the X-ray Hall, Medical Records Hall, and the front lobby without audible visual notification devices. When alarm system was initiated, these areas did not have any notification.

This deficient practice has the potential of affecting two (2) of four (4) smoke compartments. The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide a supervised automatic sprinkler system with flow switches that are electrically interconnected to the buildings fire alarm system.

Findings include:

While inspecting the sprinkler system on 5-12-11 at 1:50 p.m., the surveyor observed the fire alarm system was not monitoring the sprinkler system. At 1:45 p.m., the surveyor and the Maintenance Director performed a flow test at the inspectors test valve located in the Emergency Department (ED); after three (3) minutes of water flow it was determined the flow switch is not being monitored.

This deficient practice has the potential of affecting four (4) of four (4) smoke compartments. The Administrator and the Maintenance Director were notified during the survey and in the exit conference.

Based on observations, the facility failed to properly install and protect all of the generator ' s required components.

Findings Include:

On May 12, 2011 at appx. 11:30 a.m., the maintenance person and surveyor found that the facility lacked the required task illumination light serving the generator set location. An interview with the maintenance person revealed that the facility was unaware of the requirement.

This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey as well as the exit conference.