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The facility failed to ensure corridors were separated from use areas by walls constructed with at least a ?-hour fire resistance rating.

Observation determined the fire rated corridor walls stopped at the ceiling and did not extend to the floor/ceiling or ceiling/roof assembly.

1) The plaster covering clay tile corridor walls throughout the facility stopped at the suspended ceiling and was not applied to the clay tile block located in the interstitial space between the suspended ceilings and the floor/ceiling or the ceiling/floor decks. Without the plaster, the clay tile walls cannot attain a minimum 1/2-hour fire resistance rating.

2) A section of the second floor dining room corridor wall was not constructed with gypsum board on the room side of the wall. The gypsum board on the dining room side of the wall stopped at the suspended ceiling and did not extend to the ceiling/roof assembly. Without gypsum board applied to both sides of the wall, this section of the corridor wall cannot attain a minimum 1/2-hour fire resistance rating.

The facility failed to ensure five (5) corridor doors were substantial doors, such as those constructed of 1? inch solid-bonded core wood, equipped with automatic latching hardware suitable for keeping the doors closed and resistant to the passage of smoke. If doors are not equipped with automatic latching hardware, they must be provided with a means suitable for keeping the door closed.

Observation determined:

1) The second floor Soiled Utility Room in the south pod was not a 1 ?" solid core door. A sheet of tin was covering a louver in the door.

2) Room 112 (old shower room) was being used for storage and the door was not equipped with automatic latching hardware.

3) The Emergency Room door would not close to the latched position.

4) The two doors to the X-Ray Room would not self-close tightly to the door frame or resist the passage of smoke.

The facility failed to ensure the walls that enclose one (1) of six (6) hazardous areas were at least one-hour fire rated. The facility also failed to ensure doors to four (4) of six (6) hazardous areas were rated for at least 45 minutes and were self-closing and positive latching.

Observation determined:

1) The self-closing devices on the fire-rated doors to the Main Storage Room and Storage Room 58 were equipped with detents that held the doors in the open position and would not release upon detection of smoke in the area.

2) The fire-rated door to the Trash Room was held open with a wood wedge.

3) Approximately six (6) pipes and two (2) electrical conduit penetrations through the walls of the Trash Room were not sealed with fire rated material.

4) The door to the Clinic Records Room (Room 34 in the hospital) was not equipped with a 45-minute rated fire door.

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

To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways.

Observation determined the northeast exterior exit from St. Andrews Health Center traversed the lawn to get to a public way.

2) Keyed locks, dead bolt locks and multi-latching devices create an impediment to egress from habitable spaces. Doors shall be operable with not more than one releasing operation. 7.2.1.5.4

The facility failed to ensure exit access was readily accessible at all times.

Observation determined the corridor doors to Physical Therapy, Clinic Records, and Doctor Office were equipped with both automatic latching hardware and dead bolt locks.

The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

Note: CMS allows a light fixture equipped with a single long-life bulb (high pressure sodium or mercury vapor) with a quick strike feature to illuminate exit discharge.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness.

Observation determined the exterior light fixtures of four (4) of the seven (7) exits were long-life single-bulb light fixtures that were not equipped with quick strike.

The facility failed to ensure the fire alarm system was in compliance with NFPA 72, National Fire Alarm Code.

1) Fire alarm connections to the light and power service need to be on a dedicated branch circuit. The circuit and connections need to be mechanically protected. Circuit disconnection means must have a red marking, be accessible only to authorized personnel, and be identified as Fire Alarm Circuit Control.

Observation showed the facility failed to provide a mechanical locking device on the fire alarm electrical circuit breaker. The electrical panel containing the fire alarm circuit is located in the Mechanical Room.

2) CMS requires a photoelectric smoke detector above the fire alarm panel. If conditions do not permit a smoke detector, a rate-of-rise heat detector may be used.

Observation determined the fire alarm panel and the automatic dialer located in the Main Boiler Room were not protected with an approved device. Fixed temperature heat detectors were installed in this room.

Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications.

Review of the fire alarm test results indicated the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72.

During 2005, a new smoke detection system was installed throughout the facility. The fire alarm test records indicated the facility failed to conduct a sensitivity test on the new smoke detectors since installation.

Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of quarterly checks and maintenance of the emergency generator electrical transfer switch.