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Based on observation, interview, and a review of facility flame spread documents, the facility did not provide room finishes with rated wall finishes. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect none 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
On 6/11/2012 at 1:40 pm surveyor #12187 observed on the 1st floor in the Break room (pop machine room), that the facility could not confirm the wall had an appropriate rating. The room wall was finished with plywood in the window supporting a window air conditioning unit. 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 A (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with sealed wall penetrations, and a smoke-tight corridor ceiling (in a sprinkled smoke zone). This deficiency occurred in 5 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
1. On 6/11/2012 at 11:00 am surveyor #12187 observed on the 1st floor in the sprinkler head storage area by piano, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/11/2012 at 11:10 am surveyor #12187 observed on the 1st floor in the corridor by compactor, that penetration(s) were not sealed according to approved UL designs. The corridor was not within a fully sprinkled smoke compartment and the separation wall was required to have a 30 minute fire resistance rating, including all penetrations. Penetrations included holes around the fire alarm wire and holes by the wire shelf This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

3. On 6/11/2012 at 1:50 pm surveyor #12187 observed on the 1st floor in the closet across from pop machine room wall, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

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 affect8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
On 6/12/2012 at 9:20 am surveyor #12187 observed on the 1st floor in the Laundry, 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 A (Director of Facilities).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated doors, and sealed wall penetrations. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
1. On 6/11/2012 at 11:05 am surveyor #12187 observed on the 1st floor in the stairwell by exit to compactor, that the door in the vertical shaft wall could not be verified of having the required rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/11/2012 at 11:25 am surveyor #12187 observed on the 1st floor in the stairwell, that penetration(s) in a vertical shaft were 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), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage and with non-egress pathways without exit signs. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 6/11/2012 at 11:40 am surveyor #12187 observed on the 1st floor in the Curves weight room, that an exit sign was installed at a location that the facility confirmed was not an exit. The 'exit' went into a courtyard. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
On 6/11/2012 at 11:45 am surveyor #12187 observed on the 1st floor in the smoke barrier wall above the across corridor door by elevator south hall & by respiratory, that penetration(s) were not sealed according to approved listed testing agency designs. The deficiency included a fist size hole above the duct in the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations and rated doors. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.


FINDINGS INCLUDE:
1. On 6/12/2012 at 9:50 am surveyor #12187 observed on the 1st floor in the Laboratory, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/11/2012 at 11:20 am surveyor #12187 observed on the 1st floor in the Laundry storage and storage room by Curves, room 205 & 207, that penetration(s) were not sealed according to approved listed testing agency designs. The deficiency included holes at the perimeter. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

3. On 6/11/2012 at 11:20 am surveyor #12187 observed on the 1st floor in the Laundry storage and storage room by Curves, room 205 & 207, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide egress paths at all times with paths that are maintainable in all weather conditions and door hardware that operated with a single release motion. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
1. On 6/11/2012 at 11:30 am surveyor #12187 observed on the 1st floor in the Curves weight room, that the exit discharge path was blocked. The path was blocked by equipment so that the door would not fully swing open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/12/2012 at 3:00 pm surveyor #12187 observed on the 2nd floor in the ER utility room, that the exit discharge path was blocked. The path was blocked by equipment so that the door would not fully swing open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

3. On 6/11/2012 at 1:20 pm surveyor #12187 observed on the 1st floor in the courtyard, that the door release hardware required more than a single motion to release the door for exiting. The hardware included twisting latches for locks. 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 A (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients, and visitors.


FINDINGS INCLUDE:
1. On 6/12/2012 at 9:30 am surveyor #12187 observed on the 1st floor in the Rec room, that the clear and unobstructed width of the corridor was 5 feet. Inpatients use the 2nd exit from the recreation room since there is an exit sign above the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/11/2012 at 11:35 am surveyor #12187 observed in the 1 smoke compartment on the 1st floor in the corridor by Curves, that the clear and unobstructed width of the corridor was 6 feet because a white table obstructed the 8 foot clearance of the rest of the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not ensure corridor doors were side-hinged and were the required clear width with the proper width of doors. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.


FINDINGS INCLUDE:
On 6/12/2012 at 1:00 pm surveyor #12187 observed on the 1st floor in the Physical therapy, that the doors in the exits used by patients was narrower than the required 41.5" minimum clear width. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation, record review and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with the required quantity of drills. This deficiency occurred in all of the smoke compartments.

FINDINGS INCLUDE:
On 6/12/2012 at 7:40 am surveyor #12187 observed, that during a review of facility documents, the fire drill reports showed that fire drills were not conducted quarterly on every shift. The 3rd shift was missing in the first quarter of 2012 (January). This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The facility did not provide a fire alarm system with a smoke detector at the main fire panel. This deficiency occurred in all of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
On 6/12/2012 at 8:30 am surveyor #12187 observed on the 1st floor in the old boiler room, that the main fire alarm panel was in an area that was not continuously occupied and a smoke detector was not provided at the location. This observed situation was not compliant with NFPA 72 (1999 edition), 1-5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain every patient sleeping room with an outside window or outside door. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect all newborns.

FINDINGS INCLUDE:
On 6/12/2012 at 1:30 pm surveyor #12187 observed on the 2nd floor that the newborn nursery did not have windows to the outside. Surveyor ??? interviewed with staff ??, and was informed that there is no provision for where babies will stay if they are required to be in the hospital more than 24 hours and not in the care of their mother. It is assumed that if the baby is in the care of the mother, their primary location is the mother room which does have a window. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.8. The condition was confirmed at the time of discovery by a concurrent observation with staff A. and interview with staff ?? (RN Manager-OB?????).

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 unobstructed water distribution, sprinklers located the appropriate distance apart, and all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 4 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.


FINDINGS INCLUDE:
1. On 6/11/2012 at 1:00 pm surveyor #12187 observed on the 1st floor in the stress echo room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item . The obstruction included too small of holes in the draw curtain. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/12/2012 at 1:35 pm surveyor #12187 observed on the 2nd floor in the ER room 1, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item . The obstruction included too small of holes in the draw curtain. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

3. On 6/12/2012 at 9:00 am surveyor #12187 observed on the 1st floor in the Refuse area, that a sprinkler was located 3 feet from each other. Sprinklers cannot be closer to each other than the minimum required separation distance of 72" or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

4. On 6/12/2012 at 10:00 am surveyor #12187 observed on the 1st floor in the O.T. office, that the room was not sprinkler protected. The construction type is a Type II (0,0,0) 2 story which requires that the building be fully sprinkled. 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 A (Director of Facilities).

5. On 6/11/2012 at 11:15 am surveyor #12187 observed on the 1st floor in the home health office, that a sprinkler was located closer that 6 feet from each other Sprinklers cannot be closer to each other than the minimum required separation distance of 6' or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

6. On 6/12/2012 at 3:45 pm surveyor #12187 observed on the 2nd floor in the bathroom of clinic system analysis office, that a sprinkler was located closer than 4 inches from the wall on the ceiling. Sprinklers cannot be closer to each other than the minimum required separation distance of 6' or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

7. On 6/12/2012 at 3:35 pm surveyor #12187 observed on the 2nd floor in the visiting doctors area, that the room was not sprinkler protected. The construction type is a Type II (0,0,0) 2 story which requires that the building be fully sprinkled. 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 A (Director of Facilities).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have sprinklers free of lint, and intact escutcheon rings. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.


FINDINGS INCLUDE:
1. On 6/12/2012 at 9:15 am surveyor #12187 observed on the 1st floor in the Laundry, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/11/2012 at 11:50 am surveyor #12187 observed on the 1st floor in the Curves area and Women's Locker room, that the escutcheon ring on the sprinkler was not located adjacent to the ceiling. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A because fire dampers were missing. In addition, NFPA 90A requires damper maintenance. This deficiency occurred in all of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
1. On 6/12/2012 at 8:40 am surveyor #12187 observed on the 1st floor in the shaft between the 58 and 62 buildings, that fire dampers were not installed in an air ducts that penetrated the rated wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/12/2012 at 2:45 pm surveyor #12187 observed on the 2nd floor in the Back of sterilizer, that a fire damper was not installed in an air duct that penetrated the rated floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

3. On 6/12/2012 at 7:30 am surveyor #12187 observed, that during a review of documents it was discovered that all required maintenance procedures were not performed. Dampers were not maintained, including no visual inspection, removing the thermal link and operating the damper. 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 A (Director of Facilities).

Based on observation and interview, the facility did not provide protection of anesthetizing locations that use medical gases, as required by NFPA 99 with smoke removal system. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 6/12/2012 at 10:35 pm surveyor #12187 observed on the 2nd floor in the Operating Room, that there was no smoke removal system in this anesthetizing location. Anesthetiza gas is being administered in the Operating room created in 2010. This observed situation was not compliant with NFPA 99, (1999 edition) 5-4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide 1 of 1 interior walls and partitions made of noncombustible or limited-combustible materials with non-combustible wall materials. This deficiency occurred in 1 of 5 smoke compartments, and could affect 8 of 25 patients this facility is licensed to serve.

FINDINGS INCLUDE:
On 6/12/2012 at 2:50 pm surveyor #12187 observed on the 2nd floor in the back of sterilizer, that a wall was made with combustible materials, which is not permitted in non-combustible types of building construction. The wall was constructed with wood 2 X 4 framing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, and electrical panels with complete directories. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.


FINDINGS INCLUDE:
1. On 6/12/2012 at 8:00 am surveyor #12187 observed on the 1st floor in the kitchen, that access to electrical panel was less than 3'-0" clearance. There was equipment in front of the panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/12/2012 at 1:22 pm surveyor #12187 observed on the 2nd floor in the electrical panel by room 103, that electrical panel breaker(s) were not labeled to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation, interview, and a review of facility flame spread documents, the facility did not provide room finishes with rated wall finishes. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect none 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
On 6/11/2012 at 1:40 pm surveyor #12187 observed on the 1st floor in the Break room (pop machine room), that the facility could not confirm the wall had an appropriate rating. The room wall was finished with plywood in the window supporting a window air conditioning unit. 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 A (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with sealed wall penetrations, and a smoke-tight corridor ceiling (in a sprinkled smoke zone). This deficiency occurred in 5 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
1. On 6/11/2012 at 11:00 am surveyor #12187 observed on the 1st floor in the sprinkler head storage area by piano, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/11/2012 at 11:10 am surveyor #12187 observed on the 1st floor in the corridor by compactor, that penetration(s) were not sealed according to approved UL designs. The corridor was not within a fully sprinkled smoke compartment and the separation wall was required to have a 30 minute fire resistance rating, including all penetrations. Penetrations included holes around the fire alarm wire and holes by the wire shelf This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

3. On 6/11/2012 at 1:50 pm surveyor #12187 observed on the 1st floor in the closet across from pop machine room wall, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

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 affect8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
On 6/12/2012 at 9:20 am surveyor #12187 observed on the 1st floor in the Laundry, 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 A (Director of Facilities).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated doors, and sealed wall penetrations. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
1. On 6/11/2012 at 11:05 am surveyor #12187 observed on the 1st floor in the stairwell by exit to compactor, that the door in the vertical shaft wall could not be verified of having the required rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/11/2012 at 11:25 am surveyor #12187 observed on the 1st floor in the stairwell, that penetration(s) in a vertical shaft were 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), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage and with non-egress pathways without exit signs. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 6/11/2012 at 11:40 am surveyor #12187 observed on the 1st floor in the Curves weight room, that an exit sign was installed at a location that the facility confirmed was not an exit. The 'exit' went into a courtyard. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
On 6/11/2012 at 11:45 am surveyor #12187 observed on the 1st floor in the smoke barrier wall above the across corridor door by elevator south hall & by respiratory, that penetration(s) were not sealed according to approved listed testing agency designs. The deficiency included a fist size hole above the duct in the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations and rated doors. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.


FINDINGS INCLUDE:
1. On 6/12/2012 at 9:50 am surveyor #12187 observed on the 1st floor in the Laboratory, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/11/2012 at 11:20 am surveyor #12187 observed on the 1st floor in the Laundry storage and storage room by Curves, room 205 & 207, that penetration(s) were not sealed according to approved listed testing agency designs. The deficiency included holes at the perimeter. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

3. On 6/11/2012 at 11:20 am surveyor #12187 observed on the 1st floor in the Laundry storage and storage room by Curves, room 205 & 207, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide egress paths at all times with paths that are maintainable in all weather conditions and door hardware that operated with a single release motion. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
1. On 6/11/2012 at 11:30 am surveyor #12187 observed on the 1st floor in the Curves weight room, that the exit discharge path was blocked. The path was blocked by equipment so that the door would not fully swing open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/12/2012 at 3:00 pm surveyor #12187 observed on the 2nd floor in the ER utility room, that the exit discharge path was blocked. The path was blocked by equipment so that the door would not fully swing open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

3. On 6/11/2012 at 1:20 pm surveyor #12187 observed on the 1st floor in the courtyard, that the door release hardware required more than a single motion to release the door for exiting. The hardware included twisting latches for locks. 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 A (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients, and visitors.


FINDINGS INCLUDE:
1. On 6/12/2012 at 9:30 am surveyor #12187 observed on the 1st floor in the Rec room, that the clear and unobstructed width of the corridor was 5 feet. Inpatients use the 2nd exit from the recreation room since there is an exit sign above the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/11/2012 at 11:35 am surveyor #12187 observed in the 1 smoke compartment on the 1st floor in the corridor by Curves, that the clear and unobstructed width of the corridor was 6 feet because a white table obstructed the 8 foot clearance of the rest of the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not ensure corridor doors were side-hinged and were the required clear width with the proper width of doors. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.


FINDINGS INCLUDE:
On 6/12/2012 at 1:00 pm surveyor #12187 observed on the 1st floor in the Physical therapy, that the doors in the exits used by patients was narrower than the required 41.5" minimum clear width. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation, record review and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with the required quantity of drills. This deficiency occurred in all of the smoke compartments.

FINDINGS INCLUDE:
On 6/12/2012 at 7:40 am surveyor #12187 observed, that during a review of facility documents, the fire drill reports showed that fire drills were not conducted quarterly on every shift. The 3rd shift was missing in the first quarter of 2012 (January). This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The facility did not provide a fire alarm system with a smoke detector at the main fire panel. This deficiency occurred in all of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
On 6/12/2012 at 8:30 am surveyor #12187 observed on the 1st floor in the old boiler room, that the main fire alarm panel was in an area that was not continuously occupied and a smoke detector was not provided at the location. This observed situation was not compliant with NFPA 72 (1999 edition), 1-5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain every patient sleeping room with an outside window or outside door. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect all newborns.

FINDINGS INCLUDE:
On 6/12/2012 at 1:30 pm surveyor #12187 observed on the 2nd floor that the newborn nursery did not have windows to the outside. Surveyor ??? interviewed with staff ??, and was informed that there is no provision for where babies will stay if they are required to be in the hospital more than 24 hours and not in the care of their mother. It is assumed that if the baby is in the care of the mother, their primary location is the mother room which does have a window. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.8. The condition was confirmed at the time of discovery by a concurrent observation with staff A. and interview with staff ?? (RN Manager-OB?????).

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 unobstructed water distribution, sprinklers located the appropriate distance apart, and all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 4 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.


FINDINGS INCLUDE:
1. On 6/11/2012 at 1:00 pm surveyor #12187 observed on the 1st floor in the stress echo room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item . The obstruction included too small of holes in the draw curtain. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/12/2012 at 1:35 pm surveyor #12187 observed on the 2nd floor in the ER room 1, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item . The obstruction included too small of holes in the draw curtain. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

3. On 6/12/2012 at 9:00 am surveyor #12187 observed on the 1st floor in the Refuse area, that a sprinkler was located 3 feet from each other. Sprinklers cannot be closer to each other than the minimum required separation distance of 72" or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

4. On 6/12/2012 at 10:00 am surveyor #12187 observed on the 1st floor in the O.T. office, that the room was not sprinkler protected. The construction type is a Type II (0,0,0) 2 story which requires that the building be fully sprinkled. 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 A (Director of Facilities).

5. On 6/11/2012 at 11:15 am surveyor #12187 observed on the 1st floor in the home health office, that a sprinkler was located closer that 6 feet from each other Sprinklers cannot be closer to each other than the minimum required separation distance of 6' or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

6. On 6/12/2012 at 3:45 pm surveyor #12187 observed on the 2nd floor in the bathroom of clinic system analysis office, that a sprinkler was located closer than 4 inches from the wall on the ceiling. Sprinklers cannot be closer to each other than the minimum required separation distance of 6' or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

7. On 6/12/2012 at 3:35 pm surveyor #12187 observed on the 2nd floor in the visiting doctors area, that the room was not sprinkler protected. The construction type is a Type II (0,0,0) 2 story which requires that the building be fully sprinkled. 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 A (Director of Facilities).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have sprinklers free of lint, and intact escutcheon rings. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.


FINDINGS INCLUDE:
1. On 6/12/2012 at 9:15 am surveyor #12187 observed on the 1st floor in the Laundry, that sprinklers were not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/11/2012 at 11:50 am surveyor #12187 observed on the 1st floor in the Curves area and Women's Locker room, that the escutcheon ring on the sprinkler was not located adjacent to the ceiling. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A because fire dampers were missing. In addition, NFPA 90A requires damper maintenance. This deficiency occurred in all of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.

FINDINGS INCLUDE:
1. On 6/12/2012 at 8:40 am surveyor #12187 observed on the 1st floor in the shaft between the 58 and 62 buildings, that fire dampers were not installed in an air ducts that penetrated the rated wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/12/2012 at 2:45 pm surveyor #12187 observed on the 2nd floor in the Back of sterilizer, that a fire damper was not installed in an air duct that penetrated the rated floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

3. On 6/12/2012 at 7:30 am surveyor #12187 observed, that during a review of documents it was discovered that all required maintenance procedures were not performed. Dampers were not maintained, including no visual inspection, removing the thermal link and operating the damper. 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 A (Director of Facilities).

Based on observation and interview, the facility did not provide protection of anesthetizing locations that use medical gases, as required by NFPA 99 with smoke removal system. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 6/12/2012 at 10:35 pm surveyor #12187 observed on the 2nd floor in the Operating Room, that there was no smoke removal system in this anesthetizing location. Anesthetiza gas is being administered in the Operating room created in 2010. This observed situation was not compliant with NFPA 99, (1999 edition) 5-4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide 1 of 1 interior walls and partitions made of noncombustible or limited-combustible materials with non-combustible wall materials. This deficiency occurred in 1 of 5 smoke compartments, and could affect 8 of 25 patients this facility is licensed to serve.

FINDINGS INCLUDE:
On 6/12/2012 at 2:50 pm surveyor #12187 observed on the 2nd floor in the back of sterilizer, that a wall was made with combustible materials, which is not permitted in non-combustible types of building construction. The wall was constructed with wood 2 X 4 framing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, and electrical panels with complete directories. This deficiency occurred in 2 of the 5 smoke compartments, and had the potential to affect 8 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff, outpatients and visitors.


FINDINGS INCLUDE:
1. On 6/12/2012 at 8:00 am surveyor #12187 observed on the 1st floor in the kitchen, that access to electrical panel was less than 3'-0" clearance. There was equipment in front of the panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).

2. On 6/12/2012 at 1:22 pm surveyor #12187 observed on the 2nd floor in the electrical panel by room 103, that electrical panel breaker(s) were not labeled to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Facilities).