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Based on observations made during the survey of the facility between the hours of 10:00 am and 3:00 pm, while accompanied by the CEO, Director of Nutrition/Facilities, and the Director of Maintenance it was observed that the facility was not in compliance with the following:

The HOSPITAL and the original NURSING HOME construction are constructed with "common walls". Currently HOME HEALTH (a third occupancy) is occupying portions of the original NURSING HOME construction, and is considered to be a "B OCCUPANCY". Some of the "common walls" noted above for the HOSPITAL and the original NURSING HOME construction are walls that are shared between the HOSPITAL and the third occupancy - HOME HEALTH.
These "common walls" are required to meet the requirements of an "OCCUPANCY SEPARATION WALL" which is a 2-hour fire-rated wall. Current construction does not comply with this requirement at the following locations:
(A) Where the Hospital Dining Room shares a common wall(s) with the original Nursing Home Dining Room.
(B) Where the Hospital Central Supply Room shares multiple common walls with HOME HEALTH (including the main egress corridor within HOME HEALTH.
(C) Where the HOSPITAL "DHCHD Receiving" area (including a Vestibule room, Toilet, and 2 Closets) shares multiple common walls with HOME HEALTH.
The "DHCHD Receiving" area for the HOSPITAL includes a 48 inch wide exterior door where HOSPITAL supplies are brought from the outside loading area into a Vestibule room prior to entering the Central Supply Room. Once inside the building there is no known separation between the HOSPITAL and the adjacent HOME HEALTH occupancy.

Based on observations made during the survey of the facility between the hours of 10:00 am and 3:00 pm, while accompanied by the CEO, Director of Nutrition/Facilities, and the Director of Maintenance it was observed that the facility was not in compliance with the following:

The "AS-BUILT" drawings did not readily identify existing SMOKE COMPARTMENTATION - which there is a CODE requirement for the "subdivision" of the building into multiple SMOKE COMPARTMENTS that are separated by 1 hour fire/smoke barrier walls.

Not having this Life Safety Information (information on the required "subdivision" construction) readily identified is not acceptable for a Hospital. Hospitals need this level of information for multiple reasons: SAFETY of patients, TRAINING of staff, MAINTAINING INTEGRITY of rated construction, and REGULATORY REVIEW of their facility.

As a result of SMOKE COMPARTMENTATION not being readily identified, the Surveyor was not able to complete this part of the above ceiling survey to ensure the fire and/or smoke rated partitions are there, and that the integrity of these rated partitions is being maintained by the facility.

Provide an accurate "LIFE SAFETY PLAN" drawing showing the proper subdivision of the building. Accurately Show and Identify each existing SMOKE COMPARTMENT. In addition, all other types of existing fire & smoke rated construction information required by Code & Hospital Licensing Rules shall be readily identified and shown in the updated documentation.

Based on observations made during the survey of the facility between the hours of 10:00 am and 3:00 pm, while accompanied by the CEO, Director of Nutrition/Facilities, and the Director of Maintenance it was observed that the facility was not in compliance with the following:

The "AS-BUILT" drawings did not readily identify existing SMOKE COMPARTMENTATION - which there is a CODE requirement for the "subdivision" of the building into multiple SMOKE COMPARTMENTS that are separated by 1 hour fire/smoke barrier walls.

As a result of SMOKE COMPARTMENTATION not being readily identified, the Surveyor was not able to complete this part of the above ceiling survey to ensure the fire and/or smoke rated partitions are there, and that the integrity of these rated partitions is being maintained by the facility.