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Based on observation and interview, the facility did not provide a common separation wall with rated wall construction. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On January 28, 2013 at 1:45 pm, observation revealed on the 1st floor in the door to the nursing home by the chapel, that the separation wall was not constructed to have a 2-hour fire resistance rating because the wall was not continuous above the door to the cinder block. There was a three inch gap. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4.

On March 18, 2013, it was observed that this gap was closed by a wall that did not have 2 layers of drywall on the backside and therefore was not a two hour wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Physical Plant Director).
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Based on observation and interview, the facility did not provide corridor separation doors with double doors with an astragal seal. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

1) On January 28, 2013 at 10:45 am, observation revealed on the 1st floor in the emergency department, that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.5-exception 4.

On the original plan of correction, this item has a completion date of April 23, 2013 and observation revealed that it had not been completed as of March 18, 2013.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Physical Plant Director).
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Based on observation and interview, the facility did not provide corridor separation doors with smoke-tight seals at meeting edges. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On January 28, 2013 at 1:58 pm, observation revealed on the 1st floor in the room 114, ICU, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges, and this gap was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.1.

In the plan of correction, this item has a completion date of April 23, 2013 and observation revealed that it had not been completed as of March 18, 2013.

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

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures. This deficiency occurred in all of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On January 28, 2013 at 2:25 pm, observation revealed that staff were not familiar with their responsibilities in the event of a fire, including where the oxygen shut off valve was located for the ICU and when to shut off the oxygen supply. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.3.

On March 18, 2013 in a interview with staff CC and DD at 11:30 am, they did not know the facilities procedure for turning off the oxygen for the zone valve by respiratory area.

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

Based on observation and interview, the facility did not provide a code compliant environment with suite travel distance under the required limits. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On January 29, 2013 at 10:00 am, observation revealed on the 1st floor in the surgery suite, that the travel distance through two intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. The travel distance from OR1 to the corridor doors was 60 feet This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.8.

In the plan of correction, this item had asked for a continuation of a waiver and observation revealed that it had not been completed as of March 18, 2013.

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