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Based on observation and testing, the facility failed to provide the two hour fire separation between nonconforming building.

Findings include:

While inspecting the separation wall on December 18, 2012 at 11:30 a.m., the surveyor and maintenance director observed the two hour fire separation, that separates the hospital from administration, had numerous penetrations ranging in size from 4" x 4" to 1" x 1" around conduit and sleeves that penetrated the wall. Also some areas of the wall were not sealed to the deck above.

This deficient practice has the potential of effecting the entire facility.
The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observation the facility failed to provide the correct building construction type in accordance with 18.1.6.2,18.1.6.3, 18.2.5.1. This deficient practice has the potential of effecting the entire facility.

Findings include:

While inspecting the building construction type on December 18, 2012 at 1:30 p.m., the surveyor and Maintenance Director observed a Biohazard Room and a Soiled Linen Room constructed on the rear dock of the facility constructed out of combustible material. The two rooms were constructed from the floor to the deck above connected to the facility's canopy covering the loading dock.

The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observation, the facility failed to provide partitions that have a fire resistance rating of at least one hour.

Findings include:

While inspecting vertical openings on December 18, 2012 at 10:45 a.m., the surveyor observed the following vertical shafts had deficiencies:

1. The elevator shaft located in the rear of the kitchen had unsealed penetrations between the elevator shaft and Equipment Room.
2. The stairwell near administration had penetrations in the interior walls.

These deficient practices have the potential to effect the entire facility.
The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observations the facility failed to provide the required one hour fire resistance rating for smoke barrier walls in accordance with 18.3.7.3, 18.3.7.5, and 18.1.6.3. This condition has the potential to affect 100% of the residents and staff.

Finding include:

While inspecting smoke barrier walls on December 18, 2012 at 11:00 a.m., the maintenance supervisor and the surveyor observed that all the smoke barrier walls in the entire facility had numerous unsealed penetrations ranging in size from 4" x 4" to 1" x 1". The penetrations were around wires, conduit, and other items penetrating the smoke barrier walls. The smoke barrier walls effectiveness to compartmentalize the facility has been compromised by the number of penetrations in the smoke barrier walls.

This deficient practice has the potential of affecting 8 of 8 smoke compartments.
The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to properly provide a one-hour fire-rated barrier, with a 3/4 hour door, without windows. Doors shall be self-closing or automatic closing in accordance with 7.2.1.8 18.3.2.1. This condition affected 100% of the residents and staff.

Findings include:

While inspecting hazardous areas on December 18, 2012 at 2:30 p.m., the maintenance supervisor and the surveyor observed that all the following hazardous areas had deficiencies:

1. Dry storage room in kitchen area had penetrations.
2. Mechanical room in kitchen area had penetrations and needs a door closure.
3. 2 floor being used as storage had numerous unsealed penetrations in the rated wall and need a door closure.
4. Medical Records had numerous penetrations.
5. Film Storage Room had penetrations.
6. Room being used for film storage across from Film Storage Room had penetrations, needs a 45 minute rated door and closure.
7. Storage Room located in sleep lab area had penetrations.

This deficient practice has the potential of affecting 8 of 8 smoke compartments.
The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1. and CMS Conditions of Participation Ref: S&C -07-05. This condition had the potential to affect 50% of the staff.

Findings Include:

On December 18, 2012 at 10:45 a.m., the maintenance person and surveyor found 2 of the required exits to be inaccessible. The two exits from the old clinic by Administration lacked an all weather surface to the public way.

7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or
other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

7.1.6.4* Slip Resistance.
Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This deficient practice has the potential of affecting 2 of the required exits.
The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide a fire alarm system with approved component, devices or equipment installed according to NFPA 72, national Fire Alarm Code to provide effective warning of fire in any part of the building. This condition affected all smoke compartments.

Findings include:

While inspecting the fire alarm system on December 18, 2012, at 2:00 p.m., the maintenance person and surveyor found that the visual component of the fire alarm were not synchronized in some locations of the facility.

NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.

The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observations the facility failed to provide the required monthly generator testing in accordance with NFPA 99. This condition has the potential to affect 100% of the residents and staff.

Findings include:

While reviewing generator testing documentation on December 18, 2012 at 10:20 a.m., the facility failed to provide the yearly generator maintenance documentation for the last 12 months. The last yearly maintainable report was dated October 2011.

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 observation and testing, the facility failed to provide the two hour fire separation between nonconforming building.

Findings include:

While inspecting the separation wall on December 18, 2012 at 11:30 a.m., the surveyor and maintenance director observed the two hour fire separation, that separates the hospital from administration, had numerous penetrations ranging in size from 4" x 4" to 1" x 1" around conduit and sleeves that penetrated the wall. Also some areas of the wall were not sealed to the deck above.

This deficient practice has the potential of effecting the entire facility.
The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observation the facility failed to provide the correct building construction type in accordance with 18.1.6.2,18.1.6.3, 18.2.5.1. This deficient practice has the potential of effecting the entire facility.

Findings include:

While inspecting the building construction type on December 18, 2012 at 1:30 p.m., the surveyor and Maintenance Director observed a Biohazard Room and a Soiled Linen Room constructed on the rear dock of the facility constructed out of combustible material. The two rooms were constructed from the floor to the deck above connected to the facility's canopy covering the loading dock.

The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observation, the facility failed to provide partitions that have a fire resistance rating of at least one hour.

Findings include:

While inspecting vertical openings on December 18, 2012 at 10:45 a.m., the surveyor observed the following vertical shafts had deficiencies:

1. The elevator shaft located in the rear of the kitchen had unsealed penetrations between the elevator shaft and Equipment Room.
2. The stairwell near administration had penetrations in the interior walls.

These deficient practices have the potential to effect the entire facility.
The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observations the facility failed to provide the required one hour fire resistance rating for smoke barrier walls in accordance with 18.3.7.3, 18.3.7.5, and 18.1.6.3. This condition has the potential to affect 100% of the residents and staff.

Finding include:

While inspecting smoke barrier walls on December 18, 2012 at 11:00 a.m., the maintenance supervisor and the surveyor observed that all the smoke barrier walls in the entire facility had numerous unsealed penetrations ranging in size from 4" x 4" to 1" x 1". The penetrations were around wires, conduit, and other items penetrating the smoke barrier walls. The smoke barrier walls effectiveness to compartmentalize the facility has been compromised by the number of penetrations in the smoke barrier walls.

This deficient practice has the potential of affecting 8 of 8 smoke compartments.
The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to properly provide a one-hour fire-rated barrier, with a 3/4 hour door, without windows. Doors shall be self-closing or automatic closing in accordance with 7.2.1.8 18.3.2.1. This condition affected 100% of the residents and staff.

Findings include:

While inspecting hazardous areas on December 18, 2012 at 2:30 p.m., the maintenance supervisor and the surveyor observed that all the following hazardous areas had deficiencies:

1. Dry storage room in kitchen area had penetrations.
2. Mechanical room in kitchen area had penetrations and needs a door closure.
3. 2 floor being used as storage had numerous unsealed penetrations in the rated wall and need a door closure.
4. Medical Records had numerous penetrations.
5. Film Storage Room had penetrations.
6. Room being used for film storage across from Film Storage Room had penetrations, needs a 45 minute rated door and closure.
7. Storage Room located in sleep lab area had penetrations.

This deficient practice has the potential of affecting 8 of 8 smoke compartments.
The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1. and CMS Conditions of Participation Ref: S&C -07-05. This condition had the potential to affect 50% of the staff.

Findings Include:

On December 18, 2012 at 10:45 a.m., the maintenance person and surveyor found 2 of the required exits to be inaccessible. The two exits from the old clinic by Administration lacked an all weather surface to the public way.

7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or
other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

7.1.6.4* Slip Resistance.
Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This deficient practice has the potential of affecting 2 of the required exits.
The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide a fire alarm system with approved component, devices or equipment installed according to NFPA 72, national Fire Alarm Code to provide effective warning of fire in any part of the building. This condition affected all smoke compartments.

Findings include:

While inspecting the fire alarm system on December 18, 2012, at 2:00 p.m., the maintenance person and surveyor found that the visual component of the fire alarm were not synchronized in some locations of the facility.

NFPA 72, 4-4.4.2.3
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.

The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observations the facility failed to provide the required monthly generator testing in accordance with NFPA 99. This condition has the potential to affect 100% of the residents and staff.

Findings include:

While reviewing generator testing documentation on December 18, 2012 at 10:20 a.m., the facility failed to provide the yearly generator maintenance documentation for the last 12 months. The last yearly maintainable report was dated October 2011.

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.