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Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetrations. This deficiency occurred in 1 of the 36 smoke compartments, and would affect 0 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
On March 1, 2011 between 11:30 am to 12 noon, surveyor #18107 was told by staff in a pre-verification visit meeting on-site, this deficiency is not corrected in the 52-B1 smoke compartment on the 2nd floor that in the #2307A & #2311- Patient Storage Rooms the enclosing walls were not constructed to a 1-hour fire resistance rating. The wall had a duct penetration straddling the wall that was not sealed and fire caulked through the 1-hour concrete block wall assembly. The room was used to store patient clothing and shelves were filled from 4 inches above the floor to at least 8 feet above the floor. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of initial discussion meeting prior to start of verification visit tour with Staff CC (Mech.Util. Engr.), Staff DD (Oper. & Maint. Sprvsr.) and Staff EE (Associate Dir. - Operations).

As of 03/01/2010 the facility remains out of compliance with the above NFPA 101, 2000 Life Safety Code requirements.

Based on observation and interview, the facility did not provide and maintain multiple light fixtures or lamps in the interior and exterior means of egress so the path would still be illuminated if any single fixture or bulb failed and the egress paths would be walk-able with redundant lighting. This deficiency occurred in 2 of the 36 smoke compartments, and would affect 30 of the 120 inpatients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:

On March 1, 2011 between 10:30 am to 11:30 am surveyor #18107 observed during an on-site tour with Staff CC, DD and EE, this deficiency was not corrected at the following exit discharge at 2nd & 3rd floors in Building 5 near one of the two loading dock areas, and the path of egress to a public way is required to be lighted by a light fixture with more than one lamp should one of the lamps burn-out leaving the area in darkness outside. The lighted path to a public way shall provide at least 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. The exterior stairs area was on normal power and was missing a two-lamp fixture at exterior stairs tied to the exit discharge of Stair #5-3. This condition was observed in the path of egress to a public way.

This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4 and 7.8.2.1 illumination of means of egress shall be from a source considered reliable by the authority having jurisdiction. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) and Staff EE (Associate Dir. - Operations).

As of 03/01/2011 the facility remains out of compliance with the above 2000 NFPA 101 Life Safety Code.


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