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Based on observation and interview, the facility did not provide a common separation wall with rated doors. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect 6 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/12/2011 at 10:32 am surveyor #18107 observed in the C-1 smoke compartment on the 1st floor in the Two-hour Fire Barrier (doors), that the door in the Two-hour rated separation wall could not be verified of having at least a 90 minute rating. Observed double doors do not have a pin opening in the frame to receive the fire pin. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide and maintain the required building construction type with sealed floor penetrations, support steel covered with rated fire proofing. This deficiency occurred in 3 of the 12 smoke compartments, and had the potential to affect 5 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/11/2011 at 10:52 am surveyor #18107 observed in the One-6 smoke compartment on the 1st floor in the Electrical Closet, that fire proofing was missing from the structural steel at beam, because of two steel clamps. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

2. On 10/11/2011 at 2:08 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Trash Room, that fire proofing was missing from the structural steel at clamps in steel beams . This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

3. On 10/11/2011 at 2:28 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Maintenance Storage, that fire proofing was missing from the structural steel at floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

4. On 10/11/2011 at 2:43 PM surveyor #18107 observed in the One-4 smoke compartment in the 2nd level of the Boiler Room, that fire proofing was missing from the structural steel at floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

5. On 10/11/2011 at 3:04 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Laundry Room, that there were penetrations through the floor that were not fire stopped according to an approved method. The deficiency included numerous penetrations at the floor. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

6. On 10/11/2011 at 3:11 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Laundry Dirty Sorting Room, that fire proofing was missing from the structural steel at floor . This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

7. On 10/11/2011 at 4:19 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Corridors and Rooms in the oldest parts of the Building 1931 including 1938 & 1976 Additions, that there were penetrations through the floor that were not fire stopped according to an approved method. The deficiency included numerous unsealed holes and penetrations in the floor system at 1st, 2nd and 3rd floors of the oldest building components. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

8. On 10/12/2011 at 10:27 am surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Exit Passageway 1801 from Exit Stairwell, that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

9. On 10/11/2011 at 3:14 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Laundry Dryer & Washer Room, that fire proofing was missing from the structural steel at floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with and compliant corridor wall construction . This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect 6 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/12/2011 at 10:55 am surveyor #18107 observed in the C-2 smoke compartment on the 1st floor in the Corridor RC-801, that the corridor wall was not compliant because wall was not smoke-tight due to openings in the ceiling exposing the upper corridor wall areas above ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

2. On 10/12/2011 at 11:00 am surveyor #18107 observed in the C-2 smoke compartment on the 1st floor in the Corridor RC-104 & Hospital Vestibule 1987, that the corridor wall was not smoke tight. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

3. On 10/12/2011 at 11:05 am surveyor #18107 observed in the C-2 smoke compartment on the 1st floor in the Hospital Vestibule & Corridor 1987, that the corridor wall was not compliant because wall was not smoke-tight due to openings in the ceiling exposing the upper corridor wall areas above ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide corridor separation doors with doors that would close when pushed or pulled, compliant corridor doors, positive-latching hardware, and 20 minutes rated corridor frames. This deficiency occurred in 6 of the 12 smoke compartments, and had the potential to affect 6 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 11:22 am surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Maintenance Office, that the door to the corridor was held open with a wood wedge. The door was not equipped with a self-closing device. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

2. On 10/10/2011 at 2:51 PM surveyor #18107 observed in the Three-3 smoke compartment on the 3rd floor in the Accounts Payable Room 3027, that the door had a frame that would not resist the fire for 20 minutes because the door frame was made of wood. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1, 1999 NFPA 80 Standard for Fire Doors and Fire Windows, and NFPA 252 Standard Methods of Fire Tests of Door Assemblies or NFPA 257 Standard on Test for Windows and Glass Block Assemblies. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

3. On 10/10/2011 at 3:02 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Staff Development Administration Room, that the door had a frame that would not resist the fire for 20 minutes because the door frame was made of wood. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1, 1999 NFPA 80 Standard for Fire Doors and Fire Windows, and NFPA 252 Standard Methods of Fire Tests of Door Assemblies or NFPA 257 Standard on Test for Windows and Glass Block Assemblies. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

4. On 10/10/2011 at 3:15 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the HR Staff Toilet Room, that the door had a frame that would not resist the fire for 20 minutes because the door frame was made of wood. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1, 1999 NFPA 80 Standard for Fire Doors and Fire Windows, and NFPA 252 Standard Methods of Fire Tests of Door Assemblies or NFPA 257 Standard on Test for Windows and Glass Block Assemblies. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

5. On 10/11/2011 at 10:16 am surveyor #18107 observed in the Two-3 smoke compartment on the 2nd floor in the Crash Cart Room, that the corridor was not compliant. The glass in the corridor door did not have listed agency tested label. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

6. On 10/11/2011 at 1:49 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Gift Shop Room, that the corridor was not compliant. Glass in the door did not have any listed agency tested label. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

7. On 10/11/2011 at 4:00 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Health Information Department/ Medical Records Room, 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

8. On 10/11/2011 at 4:10 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Mail Room, that the door had a frame that would not resist the fire for 20 minutes because the door frame was made of wood. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1, 1999 NFPA 80 Standard for Fire Doors and Fire Windows, and NFPA 252 Standard Methods of Fire Tests of Door Assemblies or NFPA 257 Standard on Test for Windows and Glass Block Assemblies. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide and maintain windows to protect the corridor from non-corridor spaces with rated corridor windows. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 13 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/11/2011 at 9:15 am surveyor #18107 observed in the Two-4 smoke compartment on the 2nd floor in the window to Isolation Ante-Room, that a window was installed that provided the smoke-tightness. The window did not have a listed agency tested label similar to the other glass in the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with sealed wall penetrations, ducts in rated walls with fire dampers, non-compliant vertical opening, rated doors, and doors with positive-latching hardware. This deficiency occurred in 3 of the 12 smoke compartments, and had the potential to affect 4 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 3:10 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Human Resources (HR) Toilet Room, that penetrations in a vertical shaft were not sealed according to an approved method. The deficiency included unsealed penetrations in the chase for mechanical duct. 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

2. On 10/10/2011 at 3:38 PM surveyor #18107 observed in the Three-1 smoke compartment on the 3rd floor in the South Air Handling Unit Room, that one or more air ducts penetrated the shaft enclosure and could not be confirmed to have a properly installed fire damper. Two large air ducts could not be confirmed to have fire dampers at the floor between Surgery at 1st Floor and 3rd Floor Mechanical Room. This observed situation was not compliant with NFPA 90A (1999 edition), 3-3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

3. On 10/10/2011 at 3:42 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Utility Room, that the door in the vertical shaft wall could not be verified of having the required rating. Chute access door was made of particle wood and not fire-rated. 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

4. On 10/10/2011 at 3:51 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the 3rd Floor Closet above 2nd Floor Employee Locker Room, that the vertical shaft wall was not compliant. Bathroom exhaust duct was not enclosed in a rated shaft. 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

5. On 10/10/2011 at 4:00 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Dumbwaiter, that the door in the vertical shaft wall could not be verified of having the required rating. Dumbwaiter door was not compliant. 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

6. On 10/11/2011 at 2:40 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the exit door from upper level Boiler Room, that the door in the vertical opening would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The same door did not self close because the door was not equipped with a self closing device. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage when the egress path was not readily apparent. This deficiency occurred in 6 of the 12 smoke compartments, and had the potential to affect 12 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/11/2011 at 11:10 am surveyor #18107 observed in the One-6 smoke compartment on the 1st floor in the Emergency Department (ED) Lobby, that the egress path signage was not compliant. An exit sign was not provided at a location to assist in exiting the building. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

2. On 10/11/2011 at 1:44 PM surveyor #18107 observed in the One-3 smoke compartment on the 1st floor in the Laboratory Room, that the egress path signage was not compliant. Exit signages were not provided out of multi room suite. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

3. On 10/11/2011 at 2:58 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Utilities Management Suite, that the egress path signage was not compliant. Exit signages were missing in two locations in the path of egress. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

4. On 10/12/2011 at 9:29 am surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Corridor 3028, that the path of egress in the corridor was not readily apparent and an exit signage was not provided. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

5. On 10/12/2011 at 9:35 am surveyor #18107 observed in the Two-4 smoke compartment on the 2nd floor in the Corridor, that the path of egress in the corridor was not readily apparent and an exit signs was not provided near room number 240. Additionally in the same location at stair was mis-identified as "Not an Exit." 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

6. On 10/11/2011 at 11:12 am surveyor #18107 observed in the One-6 smoke compartment on the 1st floor in the Family Room Suite, that the egress path signage was not compliant. Exit signage was missing in a Suite. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

7. On 10/11/2011 at 1:44 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Specimen Collection Area, that the egress path signage was not compliant. Exit signage was missing. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction, sealed wall penetrations, and taped joints on rated walls. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect 6 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/12/2011 at 10:43 am surveyor #18107 observed in the C-1 smoke compartment on the 1st floor in the Cedar Room, that the smoke barrier wall was not constructed to a 1-hour fire resistance rating because top of the smoke barrier wall was open. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

2. On 10/12/2011 at 11:10 am surveyor #18107 observed in the C-2 smoke compartment on the 1st floor in the Riverside Cafe RC-109 & Dining G104, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

3. On 10/12/2011 at 10:46 am surveyor #18107 observed in the C-1 smoke compartment on the 1st floor in the Exam Room 125, that the smoke barrier wall was not constructed to a 1-hour fire resistance rating because top of the wall was not sealed with listed agency approved design and materials. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

4. On 10/12/2011 at 10:50 am surveyor #18107 observed in the C-1 smoke compartment on the 1st floor in the Electrical & Data Room RC-806, that penetrations were not sealed according to an approved method. The deficiency included twenty unsealed holes in the smoke barrier wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

5. On 10/12/2011 at 10:51 am surveyor #18107 observed in the C-2 smoke compartment on the 1st floor in the Corridor RC-801, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with an adjacent smoke detector, and compliant smoke doors. This deficiency occurred in 3 of the 12 smoke compartments, and had the potential to affect 10 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 5:30 PM surveyor #29942 observed in the One-3 smoke compartment on the 1st floor in the Kitchen room, that the smoke barrier door was magnetically held open and did not have a smoke detector within 5 feet on either side of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager).

2. On 10/10/2011 at 5:45 PM surveyor #18107 observed in the Two-2 smoke compartment on the 2nd floor in the Smoke Barrier (wall) between Smoke Compartments Two-2 and Two-1, that the smoke barrier door was not compliant. Smoke barrier doors did not close tight. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

3. On 10/11/2011 at 4:12 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the smoke barrier door at smoke barrier wall between smoke compartments One-5 and One-1, that the smoke barrier door was not compliant. When released the doors were not closed completely. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not enclose hazardous rooms with rated doors, rated walls in a sprinkled hazardous room, doors with positive-latching hardware, closer on all doors, and sealed wall penetrations. This deficiency occurred in 7 of the 12 smoke compartments, and had the potential to affect 16 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 1:35 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Elevator Equipment Control room, that penetrations were not sealed according to an approved method. The deficiency included one unsealed pipe and several conduit penetrations. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

2. On 10/10/2011 at 2:54 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Storage Room, that the fire barrier door could not be verified to have the required rating. This space had numerous combustible paper elements that were stacked high and deep within this space making this space in the judgment of the surveyor a hazardous space. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

3. On 10/10/2011 at 2:58 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Gift Shop Storage Room, that penetrations were not sealed according to an approved method. The deficiency included multiple holes in walls that are part of the stairs and missing plaster below the existing stair. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

4. On 10/10/2011 at 3:24 PM surveyor #18107 observed in the Three-1 smoke compartment on the 3rd floor in the South Penthouse Room, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall was not fire rated to its minimum requirements and per the Life Safety Plan for this hazardous space. The interior wall had exposed plastic rigid insulation. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

5. On 10/10/2011 at 3:34 PM surveyor #18107 observed in the Three-1 smoke compartment on the 3rd floor in the Emergency Generator Room, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The door would not latch because of the hardware interference at the frame and the closer was not set at a higher closer rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

6. On 10/10/2011 at 5:48 PM surveyor #18107 observed in the Two-1 smoke compartment on the 2nd floor in the Storage Room adjacent to GE Closet, that the fire barrier door could not be verified to have the required rating. The door did not have listed agency tested label. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

7. On 10/11/2011 at 10:08 am surveyor #18107 observed in the Two-3 smoke compartment on the 2nd floor in the Storage Room adjacent to 233, that the fire barrier door could not be verified to have the required rating. The door did not have listed agency tested label. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

8. On 10/11/2011 at 1:48 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Gift Shop Room, that the fire barrier door could not be verified to have the required rating. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

9. On 10/11/2011 at 2:05 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Trash Room, that the door would not self-close because the doors in two locations were not equipped with self closing devices. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

10. On 10/11/2011 at 3:30 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Wood Shop Workroom, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall was constructed to the bottom side of a duct that was running over the top of the wall. The duct does not meet the 1-hour fire resistive construction requirements. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

11. On 10/11/2011 at 3:42 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Housekeeping Storage, that the hazardous room was not compliant. Fire protection system on entire floor had been removed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

12. On 10/11/2011 at 4:05 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Air Handling Room, that the hazardous room was not compliant. Screw heads in 1-hour rated wall were not double mudded. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

13. On 10/11/2011 at 6:09 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Sterile Clean Storage Room, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall was not fire rated. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

14. On 10/11/2011 at 6:23 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Main Switchgear Room, that penetrations were not sealed according to an approved method. The deficiency included two sleeves not sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

15. On 10/10/2011 at 1:43 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Elevator Equipment Room, that the door would not self-close because the door was not equipped with automatic or self closing device and was held open. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

16. On 10/11/2011 at 3:45 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Trash Room, that the hazardous room was not compliant. Floor was assembly was not compliant. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

17. On 10/10/2011 at 1:45 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Central Penthouse room, that the fire barrier door could not be verified to have the required rating. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

Based on observation and interview, the facility did not provide enclosures around exit stairs with sealed wall penetrations, stairwell requirements, exit stairwells without openings to unoccupied rooms, rated wall construction, closer on all doors, and rated doors. This deficiency occurred in 5 of the 12 smoke compartments, and had the potential to affect 5 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 1:24 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Stair enclosure, that penetration was not sealed according to an approved method. The deficiency included a 1 inch diameter conduit penetration without firestop at wall. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

2. On 10/10/2011 at 2:18 PM surveyor #18107 observed in the Three-3 smoke compartment on the 3rd floor in the Stair #3 (north), that penetration was not sealed according to an approved method. The deficiency included 12" x 1/2" area at bottom of the wall not sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

3. On 10/11/2011 at 1:21 PM surveyor #18107 observed in the One-3 smoke compartment on the 1st floor in the Southwest Stairwell, that the stairwell was not compliant. A non-labeled door was installed. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

4. On 10/12/2011 at 9:40 am surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Stairwell opening onto Corridor #1801, that the stairwell was not compliant. Stairwell door does not swing in the direction of egress. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

5. On 10/12/2011 at 10:08 am surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Toilet room number 101, that the fire barrier door could not be verified to have the required rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

6. On 10/12/2011 at 10:10 am surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Corridor in Surgery G160 door, that the fire barrier door could not be verified to have the required rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

7. On 10/12/2011 at 9:45 am surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Exit Passageway door to Radiology Patient Holding Room 109, that the fire barrier door could not be verified to have the required rating. At the same location the door was held open without an automatic self-closing device. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

8. On 10/12/2011 at 10:12 am surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Infection Control Office G157, that the fire barrier door could not be verified to have the required rating. In the same location, door would not self close because the door was not equipped with a self closing device. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

9. On 10/12/2011 at 9:50 am surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Housekeeping Closet in the Exit Passageway next to the double Elevators, that an opening in an exit enclosure was from an unoccupied space. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

10. On 10/12/2011 at 10:23 am surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Exit Passageway 1801, that the stairwell was not compliant. Door between stairwell and exit passage way was missing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

11. On 10/12/2011 at 9:53 am surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Exit Passageway in the Corridor #1801 next to the Radiology Waiting Room., that the exit enclosure wall was not constructed to the required fire rating. All glass vision panels used in exit passageway wall did not have listed agency tested 3/4 hour fire resistive rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2, and 7.1.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

12. On 10/12/2011 at 9:59 am surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Door in Radiology Reception Room, that the fire barrier door could not be verified to have the required rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

13. On 10/12/2011 at 10:00 am surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Door in Radiology Reception Room, that the door would not self-close because the door was not equipped with self or automatic closing device. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

14. On 10/12/2011 at 10:04 am surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Bone Densitometry Room 102, that the fire barrier door could not be verified to have the required rating. In the same location, door would not self close because the door was not equipped with a self closing device. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

15. On 10/12/2011 at 10:06 am surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Public Toilet Room 103, that the fire barrier door could not be verified to have the required rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide and maintain all stairs with door assemblies, to meet code requirements with rated stairwell construction. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 3 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/11/2011 at 1:26 PM surveyor #18107 observed in the One-3 smoke compartment on the 1st floor in the Southwest Stairwell , that there was no landing at the exterior door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.3 and 7.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide egress paths at all times with doors that opened with under 50 pounds of force, level walking surface at doorways, compliant egress path , and door hardware that operated with a single release motion. This deficiency occurred in 5 of the 12 smoke compartments, and had the potential to affect 12 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/11/2011 at 5:25 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Toilet room, that the door release hardware required more than a single motion to release the door for exiting. The hardware included dead bolt. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

2. On 10/10/2011 at 2:20 PM surveyor #18107 observed in the Three-3 smoke compartment on the 3rd floor in the Roof Access, that the egress path was not compliant. The guard rail was missing at the edge of the roof area used as an egress pathway to a ladder where the roof levels are greater than 30" above one another. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.7, and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

3. On 10/10/2011 at 3:48 PM surveyor #18107 observed in the Two-1 smoke compartment on the 2nd floor in the Toilet Room across from Storage, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a dead bolt. 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

4. On 10/11/2011 at 10:14 am surveyor #18107 observed in the Two-3 smoke compartment on the 2nd floor in the Staff Locker Room, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a dead bolt. 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 C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

5. On 10/11/2011 at 10:30 am surveyor #18107 observed in the Two-4 smoke compartment on the 2nd floor in the Special Care Drug Room , that the door release hardware required more than a single motion to release the door for exiting. The hardware included a dead bolt at toilet room door. 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 C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

6. On 10/11/2011 at 11:05 am surveyor #18107 observed in the One-6 smoke compartment on the 1st floor in the Emergency Department (ED) Entrance, that the door in the path of egress would not unlatch when a force of fifteen pounds was applied, which exceeded the maximum 15 pounds needed to unlatch an existing exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

7. On 10/11/2011 at 2:00 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Materials Management, that the floor on one side of the door was greater than 1/2 inch. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.3, exception 2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

8. On 10/11/2011 at 5:21 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Toilet Room , that the door release hardware required more than a single motion to release the door for exiting. The hardware included dead bolt. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

9. On 10/11/2011 at 5:28 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Bartlett Street Exit, that the egress path was not compliant. A center stile was observed between the two door leafs at the exit discharge, which is not permitted in a hospital for bed and gurney transportation and exiting. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.7, and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

10. On 10/12/2011 at 10:07 am surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Public Toilet Room 103, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a dead bolt. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

11. On 10/12/2011 at 10:09 am surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Toilet room number 101, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a dead bolt. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

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 12 smoke compartments, and had the potential to affect 2 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/11/2011 at 4:02 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Corridor to Exit, that the clear and unobstructed width of the corridor was less than 44 inches, it should be 48 inches clear width where patients are traversing the corridor, aisle or passageway. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.3.3. . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

2. On 10/11/2011 at 4:52 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Radiology exit access, that the clear and unobstructed width of the corridor was less than 41.5 inches. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.3.3. . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide and maintain multiple fixtures or lamps in the exterior means of egress so the path would still be illuminated if any single fixture or bulb failed with and egress paths with redundant lighting. This deficiency occurred in 2 of the 12 smoke compartments, and had the potential to affect 4 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/11/2011 at 1:28 PM surveyor #18107 observed in the One-3 smoke compartment on the 1st floor in the Southwest Stairwell discharge, that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

2. On 10/11/2011 at 2:02 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Materials Management exit discharge, that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

3. On 10/11/2011 at 2:13 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the exterior of Riverside Entrance, that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

4. On 10/11/2011 at 1:30 PM surveyor #18107 observed in the One-3 smoke compartment on the 1st floor in the Southeast Stairwell discharge, that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation, interview and record review, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure. adequate testing of emergency batteries, egress lighting fed by emergency power, and an emergency battery light at the emergency generator. This deficiency occurred in 3 of the 12 smoke compartments, and had the potential to affect 15 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 3:00 PM surveyor #29942 observed that during a review of facility documents the facility did not test the battery-powered emergency lights for 30 seconds each month or 90 minutes each year. This observed situation was not compliant with NFPA 101 (2000 edition), 7.9.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager).

2. On 10/10/2011 at 1:34 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Electrical room, that a non-working battery-operated emergency light was installed in this location. This observed situation was not compliant with NFPA 101 (2000 edition), 7.9.2.3, and NFPA 110 (1999 edition), 5-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

3. On 10/10/2011 at 3:28 PM surveyor #18107 observed in the Three-1 smoke compartment on the 3rd floor in the Generator Room, that battery operated emergency lights would not turn on upon testing. This observed situation was not compliant with NFPA 101 (2000 edition), 7.9.2.3, and NFPA 110 (1999 edition), 5-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

4. On 10/11/2011 at 6:36 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Surgery Equipment Room, that the egress lighting was not compliant. The emergency light was not in a working order. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

5. On 10/10/2011 at 3:32 PM surveyor #18107 observed in the Three-1 smoke compartment on the 3rd floor in the Emergency Electrical Room to Generator Set, that battery operated emergency lights would not turn on upon testing. This observed situation was not compliant with NFPA 101 (2000 edition), 7.9.2.3, and NFPA 110 (1999 edition), 5-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

Based on observation, interview and record review, 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, and fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 12 of the 12 smoke compartments, and had the potential to affect 25 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 4:00 PM surveyor #29942 observed that during a review of facility documents the fire drill reports showed that fire drills were not conducted quarterly on every shift. No documents were found for the 1st shift of first quarter and 1st, 2nd shift of fourth quarter. 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 C (Plant Operations Manager).

2. On 10/10/2011 at 4:20 PM surveyor #29942 observed that the facility fire drill records showed that fire drills were conducted in a pattern, that they were not at unexpected times. The facility's fire drill records indicated that 3 of 3 night-shift drills were held between 6.30 AM and 6.45 AM, and 2 of the 3 day-shift fire drills were held between 3.05 PM to 3.10 PM. Fire drills were not held at unexpected times. 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 C (Plant Operations Manager).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with smoke detectors at required locations. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 1 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/11/2011 at 11:24 am surveyor #18107 observed in the One-6 smoke compartment on the 1st floor in the ED Medical Room, that the smoke detector was not located in accordance with NFPA 72 requirements. Missing smoke detector where bulkhead separated the space from corridor ceiling and ceiling was 21 inches above bulkhead. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 2-2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (Maintenance Supervisor), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers free of obstructions near the ceiling, all rooms sprinkled when the code required full sprinkling, unobstructed water distribution. This deficiency occurred in 5 of the 12 smoke compartments, and had the potential to affect 13 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 5:18 PM surveyor #18107 observed in the Two-2 smoke compartment on the 2nd floor in the Continuous Care Room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included a panel from the ceiling. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

2. On 10/11/2011 at 3:39 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Doctors Lounge Closet, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included storage items in the closet. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

3. On 10/11/2011 at 4:52 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the X-ray Film Files Storage Room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included Storage of X-ray film files. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

4. On 10/11/2011 at 5:04 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Radiology Corridor, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included Linen cart in alcove. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

5. On 10/10/2011 at 2:33 PM surveyor #18107 observed in the Three-3 smoke compartment on the 3rd floor in the IT Server Room, that the sprinkler installation was not compliant. FM 200 System was missing signage identifying that you must leave the room immediately because once the system is activated it starts removing the oxygen in the room. 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

6. On 10/11/2011 at 1:33 PM surveyor #18107 observed in the One-3 smoke compartment on the 1st floor in the Laboratory 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 missing sprinkler coverage. The space was short by 11 lineal feet to the non-covered area. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

7. On 10/11/2011 at 5:39 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Sterilizer Equipment Room, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. Missing sprinkler coverage. The space was blocked by storage equipment. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

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 verification of all monthly tests, intact escutcheon rings, a wrench in the spare sprinkler cabinet, and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 12 of the 12 smoke compartments, and had the potential to affect 25 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 2:00 PM surveyor #29942 observed that during a review of documents a monthly visual inspections of the sprinkler system that the inspections were not performed each month. Observed in record review that no visual checks and inspections were occurring on gauges, valves, and back flow for the sprinkler system. This observed situation was not compliant with NFPA 25 (998 edition), 2-2. and Table 2-1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager).

2. On 10/10/2011 at 11:20 am surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Maintenance Office, that the escutcheon ring on the sprinkler was not tight 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

3. On 10/10/2011 at 2:27 PM surveyor #18107 observed in the Three-3 smoke compartment on the 3rd floor in the Human Resources Record room, that there was one or more unsealed holes near the ceiling. The holes included several openings in the ceiling at the Records Room. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

4. On 10/10/2011 at 2:30 PM surveyor #18107 observed in the Three-3 smoke compartment on the 3rd floor in the IT Storage/ AHU serving Room, that there was one or more unsealed holes near the ceiling. The holes included portion of open ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

5. On 10/10/2011 at 2:38 PM surveyor #18107 observed in the Three-3 smoke compartment on the 3rd floor in the Housekeeping Closet, that there was one or more unsealed holes near the ceiling. The hole included a 1" diameter opening in the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

6. On 10/10/2011 at 3:00 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Gift Shop Storage Room, that there was one or more unsealed holes near the ceiling. The holes included 2 openings in the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

7. On 10/10/2011 at 3:17 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the HR Staff Toilet Room, that there was one or more unsealed holes near the ceiling. The holes included multiple holes in ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

8. On 10/10/2011 at 3:55 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Emergency Department (ED) Mechanical Room, that there was one or more unsealed holes near the ceiling. The holes included holes in the ceiling adjacent to corridor wall. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

9. On 10/10/2011 at 3:47 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Closet in the Hospice Care Room, that the escutcheon ring on the sprinkler was not tight 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

10. On 10/10/2011 at 4:02 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Emergency Department Penthouse, that the cabinet of spare sprinklers did not contain a wrench that would fit the heads in the cabinet. This observed situation was not compliant with NFPA 25 (1998 edition), 2-4.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

11. On 10/10/2011 at 5:22 PM surveyor #18107 observed in the Two-2 smoke compartment on the 2nd floor in the Respiratory Therapy Cleaning Room, that there was one or more unsealed holes near the ceiling. The hole included open ceiling around a duct. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

12. On 10/11/2011 at 9:39 am surveyor #18107 observed in the Two-4 smoke compartment on the 2nd floor in the Soiled Linen and Laundry Chute Room, that there was one or more unsealed holes near the ceiling. The holes included multiple holes. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

13. On 10/11/2011 at 10:51 am surveyor #18107 observed in the One-6 smoke compartment on the 1st floor in the Electrical Closet, that there was one or more unsealed holes near the ceiling. The holes included multiple holes. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

14. On 10/11/2011 at 11:22 am surveyor #18107 observed in the One-6 smoke compartment on the 1st floor in the ED Wiring Closet, that there was one or more unsealed holes near the ceiling. The hole included a 30 lineal feet by 9 inches opening. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 G (Maintenance Supervisor), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

15. On 10/11/2011 at 11:35 am surveyor #18107 observed in the One-6 smoke compartment on the 1st floor in the X-ray Alcove, that there was one or more unsealed holes near the ceiling. The holes included multiple holes. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 G (Maintenance Supervisor), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

16. On 10/11/2011 at 1:20 PM surveyor #18107 observed in the One-3 smoke compartment on the 1st floor in the Dietary Receiving Room 1400, that there was one or more unsealed holes near the ceiling. The holes included multiple holes. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

17. On 10/11/2011 at 1:35 PM surveyor #18107 observed in the One-3 smoke compartment on the 1st floor in the Laboratory Room, that there was one or more unsealed holes near the ceiling. The holes included multiple holes. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

18. On 10/11/2011 at 1:54 PM surveyor #18107 observed in the One-3 smoke compartment on the 1st floor in the Housekeeping Closet, that there was one or more unsealed holes near the ceiling. The holes included multiple holes. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

19. On 10/11/2011 at 2:15 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Materials Management , that there was one or more unsealed holes near the ceiling. The hole included opening in the ceiling adjacent to the door to corridor across from Maintenance office. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

20. On 10/11/2011 at 4:52 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the Dark Room, that there was one or more unsealed holes near the ceiling. The hole included a 3 inch diameter hole in the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

21. On 10/11/2011 at 5:39 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Sterile Supply Room, that there was one or more unsealed holes near the ceiling. The holes included multiple holes. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

22. On 10/11/2011 at 6:00 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Janitor Closet, that there was one or more unsealed holes near the ceiling. The holes included damaged ceiling tiles around sprinkler head. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

23. On 10/11/2011 at 6:21 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Medical Gas Manifold Room, that there was one or more unsealed holes near the ceiling. The holes included multiple holes. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

24. On 10/11/2011 at 6:32 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Janitor Closet at Decontamination Room, that there was one or more unsealed holes near the ceiling. The holes included multiple holes. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

25. On 10/11/2011 at 6:36 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Surgery Equipment Room, that the escutcheon ring on the sprinkler was missing. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

26. On 10/10/2011 at 11:21 am surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Maintenance Office, that there was one or more unsealed holes near the ceiling. The holes included four 2 inch diameter holes with conduits. Additionally in the same room, there was a 6 feet x 8 inches hole in the ceiling in front of window. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

27. On 10/11/2011 at 5:04 PM surveyor #18107 observed in the One-5 smoke compartment on the 1st floor in the X-ray Room 2, that the escutcheon ring on the sprinkler was not tight 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with and complete inspection documentation. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 8 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/11/2011 at 5:35 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Surgery Area, that during a review of documents records were not available to confirm that fire extinguishers were inspected . During the observation, CO2 based portable fire extinguishers were found not inspected in the last 12 months or tested in the last one year. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.6, 9.7.4.1 and NFPA 10. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

2. On 10/11/2011 at 5:36 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Endoscope Procedure Room, that during a review of documents, records were not available to confirm that fire extinguishers were inspected or serviced by the security. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.6, 9.7.4.1 and NFPA 10. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation, interview and record review, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with ventilation systems that comply with NFPA 90A, missing fire damper and neutral airflow between the corridor and rooms. This deficiency occurred in 3 of the 12 smoke compartments, and had the potential to affect 6 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 3:30 PM surveyor #29942 observed that the space was not provided with compliant ventilation. It was observed that during document review that no documents were found for all smoke and fire damper were inspected in the last the last six years. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition). . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager).

2. On 10/11/2011 at 2:11 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Trash Room, that a fire damper was not installed in an air duct 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. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

3. On 10/11/2011 at 2:32 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Maintenance Storage, that a fire damper was not installed in an air duct that penetrated the rated floor. Missing four (4) fire dampers in the exhaust duct penetrating through three floors. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

4. On 10/11/2011 at 3:00 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Maintenance Locker Room, 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), 3-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

5. On 10/11/2011 at 2:59 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Maintenance Locker Room, that airflow between the corridor and this room was not neutral. Exhaust from the toilet was not in working order, thereby causing the air to be pushed out into the corridor creating a air plenum in the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

6. On 10/11/2011 at 5:43 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Sterilizer Equipment Room, that airflow between the corridor and this room was not neutral. The 2 sterilizers are missing a exhaust vent at the front of the steam sterilizers to catch the excessive steam upon opening the sterilizer equipment doors. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96. hood per the code, and extinguisher identification. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 1 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 5:20 PM surveyor #29942 observed in the One-3 smoke compartment on the 1st floor in the Kitchen room, that the kitchen hood suppression system was not compliant. Three large carts were placed in front of the kitchen hood suppression system manual pull station. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.6, 9.2.3 and NFPA 96. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager).

2. On 10/10/2011 at 5:31 PM surveyor #29942 observed in the One-3 smoke compartment on the 1st floor in the Kitchen room, that the kitchen hood suppression system was not compliant. A placard sign was missing above the pull station. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.6, 9.2.3 and NFPA 96. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager).

3. On 10/10/2011 at 5:25 PM surveyor #29942 observed in the One-3 smoke compartment on the 1st floor in the Kitchen room, that a placard identification sign was not provided above the Type K fire extinguisher to identify its location. This observed situation was not compliant with NFPA 96 (1998 edition), Section 7-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager).

Based upon observation, the facility did not provide a properly enclosed linen/trash chute and appropriate collection rooms as with compliant chutes. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 1 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/11/2011 at 3:30 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Laundry Chute Room, that the chute was not compliant. Numerous unsealed penetrations in the ceiling and in the rated walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on interview and observation, the facility did not provide toilet shower curtains that permit the designed distribution of sprinkler water. This deficiency occurred in 3 of the 12 smoke compartments, and had the potential to affect 15 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 2:40 PM surveyor #18107 observed in the Three-3 smoke compartment on the 3rd floor in the Staff Shower Room, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

2. On 10/11/2011 at 9:37 am surveyor #18107 observed in the Two-4 smoke compartment on the 2nd floor in the Patient Room 214, that a toilet shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

3. On 10/11/2011 at 9:41 am surveyor #18107 observed in the Two-3 smoke compartment on the 2nd floor in the Patient Room 216, that a toilet shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

4. On 10/11/2011 at 10:04 am surveyor #18107 observed in the Two-3 smoke compartment on the 2nd floor in the Patient Room 233, that a toilet shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

5. On 10/11/2011 at 10:11 am surveyor #18107 observed in the Two-3 smoke compartment on the 2nd floor in the Patient Room 234, that a toilet shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

6. On 10/11/2011 at 10:26 am surveyor #18107 observed in the Two-4 smoke compartment on the 2nd floor in the Patient Room 241, that a toilet shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

7. On 10/11/2011 at 9:43 am surveyor #18107 observed in the Two-3 smoke compartment on the 2nd floor in the Patient Room 217, that a toilet shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

8. On 10/11/2011 at 10:06 am surveyor #18107 observed in the Two-3 smoke compartment on the 2nd floor in the Patient Room 236, that a toilet shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

9. On 10/11/2011 at 10:12 am surveyor #18107 observed in the Two-3 smoke compartment on the 2nd floor in the Patient Room 232, that a toilet shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

10. On 10/11/2011 at 9:45 am surveyor #18107 observed in the Two-3 smoke compartment on the 2nd floor in the Patient Room 219, that a toilet shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

11. On 10/11/2011 at 9:46 am surveyor #18107 observed in the Two-3 smoke compartment on the 2nd floor in the Patient Room 223, that a toilet shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with compliant rooms, and closer on all doors. This deficiency occurred in 2 of the 12 smoke compartments, and had the potential to affect 12 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/11/2011 at 2:54 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Oxygen Storage Room, that the oxygen area was not compliant. Electrical switches located within five feet above the floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), 8-3.1.11. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

2. On 10/11/2011 at 6:19 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Medical Gas Manifold Room, that the door did not self-close because door did not equipped with a self closing device, additionally the same door did not latch positively. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), 8-3.1.11. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 6 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/11/2011 at 6:01 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Surgical Suite, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included arrows on piping were not pointing in the correct direction. The Vacuum line should be pointing in a opposite direction from the Medical Air and Oxygen lines. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), Chap 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide and maintain the required building construction type with a compliant type of construction, support steel covered with rated fire proofing, and support steel covered with rated fire proofing. This deficiency occurred in 2 of the 3 smoke compartments, and had the potential to affect 3 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/12/2011 at 2:30 PM surveyor #18107 observed in the Rehab-2 smoke compartment on the 2nd floor in the Northeast Stairwell, that fire proofing was missing from the structural steel at an area of 2' x 12' exposing the stairwell ceiling. The original fire protection was removed during a renovation. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.12.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

2. On 10/12/2011 at 2:42 PM surveyor #18107 observed in the Rehab-2 smoke compartment on the 2nd floor in the Northwest Stairwell, that the building's construction type was not compliant because the use of exposed combustible wood located above sprinkler protection at stairwell ceiling. Fire protection was removed during one of the renovations. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.12.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

3. On 10/12/2011 at 3:10 PM surveyor #18107 observed in the Rehab-B smoke compartment on the Basement floor in the Housekeeping Storage, that fire proofing was missing from the structural steel beam. Three steel clamps were installed on the steel beam and not protected. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.12.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

4. On 10/12/2011 at 3:20 PM surveyor #18107 observed in the Rehab-B smoke compartment on the Basement floor in the Main Electrical Room (1600 AMPS), that fire proofing was missing from the structural steel at multiple steel anchors and pins that were attached to steel beam were not protected. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.12.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not enclose hazardous rooms with closer on all doors, smoke tight walls in a sprinkled hazardous room. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect 3 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/12/2011 at 2:38 PM surveyor #18107 observed in the Rehab-2 smoke compartment on the 2nd floor in the Speech Therapy Storage, that the door would not self-close because the three doors were not equipped with a automatic or self closing device. The room was considered hazardous because it contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 39.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

2. On 10/12/2011 at 2:58 PM surveyor #18107 observed in the Rehab-B smoke compartment on the Basement floor in the Furnace Room, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall included multiple holes. The room was considered hazardous because it contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 39.3.2.1. and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

3. On 10/12/2011 at 3:15 PM surveyor #18107 observed in the Rehab-B smoke compartment on the Basement floor in the Main Electrical Room (1600 AMPS), that the hazardous room was not compliant. Top of the wall was not sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 39.3.2.1. and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide and maintain multiple fixtures or lamps in exterior means of egress so the path would still be illuminated if any single fixture or bulb failed with egress paths with redundant lighting. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect 3 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/12/2011 at 2:21 PM surveyor #18107 observed in the Rehab-1 smoke compartment on the 1st floor in the exterior of Rehab Area at the South Exit discharge, that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with and sprinklers free of obstructions near the ceiling. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect 3 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/12/2011 at 2:45 PM surveyor #18107 observed in the Rehab-B smoke compartment on the Basement floor in the Women's Locker & Shower Room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included toilet partition. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. 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 C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

2. On 10/12/2011 at 2:50 PM surveyor #18107 observed in the Rehab-B smoke compartment on the Basement floor in the Men's Locker & Shower Room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included toilet partition. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. 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 C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

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 sealed ceilings above the sprinklers to collect heat. This deficiency occurred in 2 of the 3 smoke compartments, and had the potential to affect 3 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/12/2011 at 2:28 PM surveyor #18107 observed in the Rehab-1 smoke compartment on the 1st floor in the Soiled Linen Room, that there was one or more unsealed holes near the ceiling. The holes included multiple holes. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

2. On 10/12/2011 at 2:40 PM surveyor #18107 observed in the Rehab-2 smoke compartment on the 2nd floor in the Small Speech Therapy Room, that there was one or more unsealed holes near the ceiling. The hole included a missing ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 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 C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with neutral airflow between the corridor and rooms. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect 3 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/12/2011 at 2:27 PM surveyor #18107 observed in the Rehab-1 smoke compartment on the 1st floor in the Soiled Linen Room, that airflow between the corridor and this room was not neutral. The exhaust vent was missing, causing the air to be pushed into the corridor, creating the corridor to be a air plenum. This observed situation was not compliant with NFPA 101 (2000 edition), 39.5.2, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with electrical panels with complete directories, working clearances at electrical panels and non-compliant exiting from electrical room. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect 3 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/12/2011 at 2:17 PM surveyor #18107 observed in the Rehab-1 smoke compartment on the 1st floor in the Office, that electrical panel breakers 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 C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

2. On 10/12/2011 at 3:12 PM surveyor #18107 observed in the Rehab-B smoke compartment on the Basement floor in the Main Electrical Room (1600 AMPS), that the electrical code was not followed. Electrical equipments rated more than 1200 Amps and panic hardware on the door had only lever handle. This observed situation was not compliant with NFPA 70 (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

3. On 10/12/2011 at 2:18 PM surveyor #18107 observed in the Rehab-1 smoke compartment on the 1st floor in the Office, that access to electrical panel was less than 3'-0" clearance. 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 C (Plant Operations Manager), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide a code compliant environment with and compliant emergency showers. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 5 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/11/2011 at 5:58 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the OR - B (outside room), that the eye wash station was missing the spray bottles to wash the eyes in the event of a chemical spill in Surgery. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and NFPA 99 (1999 edition), 10.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

2. On 10/11/2011 at 6:30 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Decontamination Room, that The eye wash station was missing the spray bottles to wash the eyes in the event of a chemical spill. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and NFPA 99 (1999 edition), 10.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with weekly inspections of the emergency generators, and full documentation of monthly generator testing. This deficiency occurred in 12 of the 12 smoke compartments, and had the potential to affect 21 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 2:30 PM surveyor #29942 observed that during a review of facility documents on weekly visual inspections of the generator that the inspections were not performed each week. Observed in record review that no visual checks and inspections were occurring on fuel level, float switches, hoses, lube oil level, lube oil heater operation, coolant level, radiator cleanliness, water pump, hoses, exhaust system, and electrical system general inspection. This observed situation was not compliant with NFPA 110 (1999 edition), 6-4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager).

2. On 10/10/2011 at 3:45 PM surveyor #29942 observed that during a review of facility documents there was no written record indicating the emergency generator was exercised for 30 minutes each month at the appropriate operating temperature, or with a load that exceeded 30% of the nameplate rating or at the minimum exhaust gas temperature for the month of March and April of 2011. This observed situation was not compliant with NFPA 110 (1999 edition), 6-4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with non-compliance, electrical panels with complete directories, closed electrical raceways, and working clearances at electrical panels. This deficiency occurred in 9 of the 12 smoke compartments, and had the potential to affect 15 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 5:15 PM surveyor #29942 observed in the One-3 smoke compartment on the 1st floor in the Kitchen room, that the electrical code was not followed. Two electrical outlets were within 3 feet of a sink without any ground fault circuit interruption. This observed situation was not compliant with NFPA 70 (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager).

2. On 10/10/2011 at 1:29 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the Central Penthouse room, that electrical panel breakers 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

3. On 10/10/2011 at 2:29 PM surveyor #18107 observed in the Three-3 smoke compartment on the 3rd floor in the IT Storage/ AHU serving Room, that a 4" x 4" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

4. On 10/10/2011 at 3:20 PM surveyor #18107 observed in the Three-1 smoke compartment on the 3rd floor in the South Penthouse Room, that electrical panel breakers 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 E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

5. On 10/11/2011 at 9:20 am surveyor #18107 observed in the Two-4 smoke compartment on the 2nd floor in the Nurse Station at Pharmacy Cabinet, that access to electrical panel was less than 3'-0" clearance. Five electrical panels were obstructed by large medical equipment. 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 C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

6. On 10/11/2011 at 9:51 am surveyor #18107 observed in the Two-3 smoke compartment on the 2nd floor in the Pantry Room, that the electrical code was not followed. Electrical outlets were located within the 22 inches of sink without ground fault circuit interruption. This observed situation was not compliant with NFPA 70 (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

7. On 10/11/2011 at 10:24 am surveyor #18107 observed in the Two-4 smoke compartment on the 2nd floor in the Corridor - Special Care Wing, that electrical panel breakers 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 C (Plant Operations Manager), staff E (Safety Officer), staff F (Facilities Mgmt Supervisor), and staff G (Maintenance Supervisor).

8. On 10/11/2011 at 11:55 am surveyor #18107 observed in the One-6 smoke compartment on the 1st floor in the Triage Exam Room, that the electrical code was not followed. Electrical outlets were located within 24 inches of a sink without ground fault circuit interruption. This observed situation was not compliant with NFPA 70 (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff G (Maintenance Supervisor), staff E (Safety Officer) and staff F (Facilities Mgmt Supervisor).

9. On 10/11/2011 at 2:35 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Maintenance Storage, that access to electrical panel was less than 3'-0" clearance. The electrical panel include large switchgear rated 800 amps. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

10. On 10/11/2011 at 3:19 PM surveyor #18107 observed in the One-4 smoke compartment on the 1st floor in the Wood Shop Workroom, that the electrical code was not followed. Water on floor across the room and that room was used by carpenters to cut wood trim, three large pieces of equipments were plugged in the receptacles that did not have ground fault circuit interruption. This observed situation was not compliant with NFPA 70 (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

11. On 10/11/2011 at 6:20 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Medical Gas Manifold Room, that a two gang electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

12. On 10/11/2011 at 6:22 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Main Switchgear Room, that three 4" x 4" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

13. On 10/11/2011 at 5:27 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Domestic Water Supply Room and Sprinkler Main Room, that a electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

14. On 10/11/2011 at 6:33 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Surgery Equipment Room, that access to electrical panel was less than 3'-0" clearance. 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 C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on observation and interview, the facility did not provide and use a program to respond to outages of the sprinkler system with complete procedures for responding to outages. This deficiency occurred in 12 of the 12 smoke compartments, and had the potential to affect 25 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/10/2011 at 4:30 PM surveyor #29942 observed that during a review of facility documents the facility did not have an appropriate response to outages of the sprinkler system of more than 4 hours in a 24 hour period. The facility policy only states the situation for fire alarm outages. In addition, an approved fire watch policy does mention for a 'trained person' and appropriate logging of the findings during FIRE WATCH. This observed situation was not compliant with NFPA 101 (2000 edition), 9.7.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager).