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The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating as required and in accordance the LSC.

1. On 05/13/10 at 09:35 A.M. the surveyor while accompanied by the Director of Maintenance, observed that the smoke barrier walls located above the ceiling in the A-4 Pantry contained voids around penetrations by electrical conduits that were not sealed/protected by materials having a 30-minute fire resistance rating as required by the referenced LSC.

2. On 05/13/10 at 10:35 A.M. the surveyor while accompanied by the Director of Maintenance, observed that the smoke barrier walls located above the ceiling in the A-3 Pantry contained voids around penetrations by electrical conduits & waste & drain cast iron piping that were not sealed/protected by materials having a 30-minute fire resistance rating as required by the referenced LSC; i.e. large piece of drywall (roughly 12 " X16 " ) removed.

3. On 05/13/10 at 11:00 A.M. the surveyor while accompanied by the Director of Maintenance, observed that the smoke barrier walls located above the ceiling in the E-2 Conference Room (E-260) contained voids around penetrations by an electrical cable tray was not sealed/protected by materials having a 30-minute fire resistance rating as required by the referenced LSC; i.e. insulation stuffed in one side of wall-no seal, not smoke tight or fire resistant.

4. On 05/13/10 at 1:20 P.M. the surveyor while accompanied by the Director of Maintenance, observed that the smoke barrier walls located above the ceiling in the D-1 Kitchenette contained voids around penetrations by electrical conduits & waste & drain cast iron piping that were not sealed/protected by materials having a 30-minute fire resistance rating as required by the referenced LSC; i.e. large pieces of drywall removed or not installed.

The facility did not ensure that door openings in smoke barriers have at least a 20-minute fire protection rating or are at least 1¾-inch thick solid bonded wood core. Doors are self-closing or automatic closing in accordance with the referenced LSC 19.2.2.2.6.

1. On 05/13/10 at 10:55 A.M. the surveyor while accompanied by the Director of Maintenance, observed that the door to the E-2 Conference Room (E-260) was not provided with a self-closing device as required by the referenced LSC.
2. On 05/13/10 at 12:45 P.M. the surveyor while accompanied by the Director of Maintenance, observed that the door to the D-1 Community Room was not provided with a self-closing device as required by the referenced LSC.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

On 05/14/10 at 10:30 AM, The surveyor was not provided with documentation by the Director of Maintenance that indicated the dry pipe sprinkler system had been trip tested annually and/or full flood trip tested every three years as required by NFPA 25

1. The facility did not ensure that Emergency and Standby Power Systems were being inspected and maintained as required in NFPA 110 " Standard for Emergency and Standby Power Systems " .


On 05/14/10 at 11:00 AM, the surveyor was not provided with documentation by the Director of Maintenance that the facility's emergency generator was being maintained as required by NFPA 110 " Standard for Emergency and Standby Power Systems " Chapter 6 section 1.1 i.e. no Level 1 maintenance conducted in calendar year 2009 or to this date 2010.

2. The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99 " Health Care Facilities " .

On 05/14/10 at 11:00 AM, the surveyor was not provided with documentation by the Director of Maintenance that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program, last documented inspection 2005.

The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating as required and in accordance the LSC.

1. On 05/13/10 at 09:35 A.M. the surveyor while accompanied by the Director of Maintenance, observed that the smoke barrier walls located above the ceiling in the A-4 Pantry contained voids around penetrations by electrical conduits that were not sealed/protected by materials having a 30-minute fire resistance rating as required by the referenced LSC.

2. On 05/13/10 at 10:35 A.M. the surveyor while accompanied by the Director of Maintenance, observed that the smoke barrier walls located above the ceiling in the A-3 Pantry contained voids around penetrations by electrical conduits & waste & drain cast iron piping that were not sealed/protected by materials having a 30-minute fire resistance rating as required by the referenced LSC; i.e. large piece of drywall (roughly 12 " X16 " ) removed.

3. On 05/13/10 at 11:00 A.M. the surveyor while accompanied by the Director of Maintenance, observed that the smoke barrier walls located above the ceiling in the E-2 Conference Room (E-260) contained voids around penetrations by an electrical cable tray was not sealed/protected by materials having a 30-minute fire resistance rating as required by the referenced LSC; i.e. insulation stuffed in one side of wall-no seal, not smoke tight or fire resistant.

4. On 05/13/10 at 1:20 P.M. the surveyor while accompanied by the Director of Maintenance, observed that the smoke barrier walls located above the ceiling in the D-1 Kitchenette contained voids around penetrations by electrical conduits & waste & drain cast iron piping that were not sealed/protected by materials having a 30-minute fire resistance rating as required by the referenced LSC; i.e. large pieces of drywall removed or not installed.

The facility did not ensure that door openings in smoke barriers have at least a 20-minute fire protection rating or are at least 1¾-inch thick solid bonded wood core. Doors are self-closing or automatic closing in accordance with the referenced LSC 19.2.2.2.6.

1. On 05/13/10 at 10:55 A.M. the surveyor while accompanied by the Director of Maintenance, observed that the door to the E-2 Conference Room (E-260) was not provided with a self-closing device as required by the referenced LSC.
2. On 05/13/10 at 12:45 P.M. the surveyor while accompanied by the Director of Maintenance, observed that the door to the D-1 Community Room was not provided with a self-closing device as required by the referenced LSC.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

On 05/14/10 at 10:30 AM, The surveyor was not provided with documentation by the Director of Maintenance that indicated the dry pipe sprinkler system had been trip tested annually and/or full flood trip tested every three years as required by NFPA 25

1. The facility did not ensure that Emergency and Standby Power Systems were being inspected and maintained as required in NFPA 110 " Standard for Emergency and Standby Power Systems " .


On 05/14/10 at 11:00 AM, the surveyor was not provided with documentation by the Director of Maintenance that the facility's emergency generator was being maintained as required by NFPA 110 " Standard for Emergency and Standby Power Systems " Chapter 6 section 1.1 i.e. no Level 1 maintenance conducted in calendar year 2009 or to this date 2010.

2. The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99 " Health Care Facilities " .

On 05/14/10 at 11:00 AM, the surveyor was not provided with documentation by the Director of Maintenance that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program, last documented inspection 2005.