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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 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 10:45 am, and on July 21, 2014 at 10:30 am observation revealed on the Basement floor in the Corridor to the PT area, that the clear and unobstructed width of the corridor was six feet. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Staff A mentioned that this Corridor is occasionally used by in- patients. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).

Waiver Granted.

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes for a generator with a remote stop and trouble signals at a continuously monitored location by operating personnel. This deficiency occurred in 11 of the 11 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 06/03/2014 at 11:10 am, and on July 21, 2014 at 10:45 am, observation revealed on the 1st floor in the Type 1 Generator Room, that the emergency generator was not provided with a remote stop switch outside the Generator Room. On July 21, 2014 wire had been pulled, but the connections had not been done. This observed situation was not compliant with NFPA 110 (1999 ed.), 3-5.5.6.

2. On 06/03/2014 at 11:15 am and on July 21, 2014 at 10:45 am, observation revealed on the 1st floor in the Generator Room, that a remote annunciator with storage battery power, was not provided in a location outside of the generating room that was in view of plant operating personnel of a regular work station. On July 21, 2014 wire had been pulled, but the connections had not been done. This Type 1 remote annunciator was only provided at a nurse station. This observed situation was not compliant with NFPA 99 (1999 ed.), 3-4.1.1.15.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance Director).