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The facility did not maintain the fire resistive ratings of ceilings in patient rooms.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections 19.1.6.2, 19.1.6.3, 19.1.6.4, or 19.3.5.1. "Section 19.1.6.2," "Health Care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2."

On August 10, 2010, the surveyor, accompanied by the Director of Maintenance, observed the ceiling concealed automatic sprinklers in patient rooms 408 and 412. The sprinkler cap was flush to the dry wall but there was a 1/4 inch to 1/2 inch opening around the entire sprinkler assembly.

The facility failed to fill holes in a fire resistive/smoke resistive ceilings. Failing to contain smoke or heat from a fire will cause harm to the patients.

The facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

On August 10, 2010, the surveyor, accompanied by the Director of Maintenance, observed that the following corridor doors would not close on fire alarm, would not latch, or close tightly.

1. Patient room door 107 had the automatic door closer disconnected.
2. Patient room door 109 was missing the positive latching hardware.
3. Patient room door 113 had the automatic door closer disconnected.
4. Patient room door 208 had the automatic door closer disconnected.
5. Patient room door 313 would not tightly close when tested.
6. Patient room door 507 would not tightly close when tested.
7. Patient room door 513 had the automatic foor closer disconnected.
8. Patient room door 607 had the automatic door closer disconnected.
9. Patient room door 608 did not latch when tested.
10. Patient room door 610 was missing the positive latching hardware.

In time of a fire failing to protect patients from heat and smoke will cause harm to the patients.

The facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.


On August 10, 2010, the surveyor, accompanied by the Director of Maintenance, observed unsealed penetrations in the smoke barrier located on the second floor at the clean utility room. There also was a 2" X 3" hole in the corridor wall above the door across from the clean utility room.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

The facility failed to replace burned, melted, light fixture covers.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage

On August 10, 2010, the surveyor, accompanied by the Director of Maintenance, observed that the three seclusion rooms, between wing 400 and 600, had burned and melted ceiling light fixture covers.

Failure to repair broken or burned light fixture covers could cause harm to the patients.