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Based on observation and record review, it was determined that the facility has not maintained the building construction type to comply with the requirements of NFPA 101, LSC, Section 19.1.6.2. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the fire causes a collapse of the structure earlier than anticipated or planned for due to improper construction type.

Findings include:

On April 19, 2011 at approximately 10:45 a.m. during record review, it was noted that the "Master First Floor Plan Fire and Smoke Barrier" drawing (Sheet A2.01) Code Summary states that the roof construction is of a 1-hour rating. Observation of the critical care and medical/surgical areas of the facility showed unprotected bar joist structural support. The attached acoustical ceiling was found to have recessed lighting fixtures which were not "tented" as required by U.L. designs. This ceiling assembly also was observed to support other systems such as electrical conduits which had been clipped to the channel support wires and the lighting fixtures were not supported independently. The facility was unable to provide documentation that the roof/ceiling assembly was a 1-hour rated assembly as currently constructed. With the lack of documentation that the roof/ceiling structure is in fact 1-hour, the construction type would properly be of Type II(000). This construction type requires sprinkler protection throughout, which is not present.

Based on observation and record review, it was determined that the facility has not maintained the building construction type to comply with the requirements of NFPA 101, LSC, Section 19.1.6.2. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the fire causes a collapse of the structure earlier than anticipated or planned for, due to improper construction type or lack of sprinkler protection as required.

Findings include:

On April 19, 2011 at approximately 10:45 a.m. during record review, it was noted that the "Master First Floor Plan Fire and Smoke Barrier" drawing (Sheet A2.01) Code Summary states that the roof construction is of a 1-hour rating. Observation of the critical care and medical/surgical areas of the facility showed unprotected bar joist structural support. The attached acoustical ceiling was found to have recessed lighting fixtures which were not "tented" as required by U.L. designs. This ceiling assembly also was observed to support other systems such as electrical conduits which had been clipped to the channel support wires and the lighting fixtures were not supported independently. The facility was unable to provide documentation that the roof/ceiling assembly was a 1-hour rated assembly as currently constructed. With the lack of documentation that the roof/ceiling structure is in fact 1-hour, the construction type would properly be of Type II(000). This construction type requires sprinkler protection throughout, which is not present.

Based on observation it was determined that the facility failed to maintain the required automatic sprinkler system in a continuously reliable operating condition in accordance with NFPA 101, LSC, Sections 19.7.6, 4.6.12 and 9.7.5 and NFPA 25. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the fire cannot be rapidly controlled or extinguished due to oa failure of improperly maintained sprinkler heads in the kitchen area.

Findings include:

On April 19, 2011 at approximately 12:37 p.m., approximately ten automatic sprinkler heads were observed to be covered with green corrosion. This finding was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to provide portable fire extinguishers in accordance with NFPA 101, LSC, Sections 19.3.5.6, 9.7.4.1 and NFPA 10. This deficient practice could affect all patients, staff and visitors in the event of a fire where the fire could not be rapidly extinguished due to improperly maintained extinguishers.

Findings include:

On April 19, 2011 between 12:30 p.m. and 2:30 p.m., fire extinguishers located throughout the facility were observed to not have any six year maintenance collars or six year maintenance labels affixed to the extinguishers. All extinguishers were observed to have a date of manufacture of 1992 or 1996. One fire extinguisher in the medical/surgical wing was observed to have a six year maintenance collar with no dates punched which was cut and placed on the fire extinguisher below the valve stem assembly, but the required six year label was dated 1993.

Based on observation and record review, it was determined that the facility has not maintained the building construction type to comply with the requirements of NFPA 101, LSC, Section 19.1.6.2. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the fire causes a collapse of the structure earlier than anticipated or planned for due to improper construction type.

Findings include:

On April 19, 2011 at approximately 10:45 a.m. during record review, it was noted that the "Master First Floor Plan Fire and Smoke Barrier" drawing (Sheet A2.01) Code Summary states that the roof construction is of a 1-hour rating. Observation of the critical care and medical/surgical areas of the facility showed unprotected bar joist structural support. The attached acoustical ceiling was found to have recessed lighting fixtures which were not "tented" as required by U.L. designs. This ceiling assembly also was observed to support other systems such as electrical conduits which had been clipped to the channel support wires and the lighting fixtures were not supported independently. The facility was unable to provide documentation that the roof/ceiling assembly was a 1-hour rated assembly as currently constructed. With the lack of documentation that the roof/ceiling structure is in fact 1-hour, the construction type would properly be of Type II(000). This construction type requires sprinkler protection throughout, which is not present.

Based on observation and record review, it was determined that the facility has not maintained the building construction type to comply with the requirements of NFPA 101, LSC, Section 19.1.6.2. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the fire causes a collapse of the structure earlier than anticipated or planned for, due to improper construction type or lack of sprinkler protection as required.

Findings include:

On April 19, 2011 at approximately 10:45 a.m. during record review, it was noted that the "Master First Floor Plan Fire and Smoke Barrier" drawing (Sheet A2.01) Code Summary states that the roof construction is of a 1-hour rating. Observation of the critical care and medical/surgical areas of the facility showed unprotected bar joist structural support. The attached acoustical ceiling was found to have recessed lighting fixtures which were not "tented" as required by U.L. designs. This ceiling assembly also was observed to support other systems such as electrical conduits which had been clipped to the channel support wires and the lighting fixtures were not supported independently. The facility was unable to provide documentation that the roof/ceiling assembly was a 1-hour rated assembly as currently constructed. With the lack of documentation that the roof/ceiling structure is in fact 1-hour, the construction type would properly be of Type II(000). This construction type requires sprinkler protection throughout, which is not present.

Based on observation it was determined that the facility failed to maintain the required automatic sprinkler system in a continuously reliable operating condition in accordance with NFPA 101, LSC, Sections 19.7.6, 4.6.12 and 9.7.5 and NFPA 25. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the fire cannot be rapidly controlled or extinguished due to oa failure of improperly maintained sprinkler heads in the kitchen area.

Findings include:

On April 19, 2011 at approximately 12:37 p.m., approximately ten automatic sprinkler heads were observed to be covered with green corrosion. This finding was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to provide portable fire extinguishers in accordance with NFPA 101, LSC, Sections 19.3.5.6, 9.7.4.1 and NFPA 10. This deficient practice could affect all patients, staff and visitors in the event of a fire where the fire could not be rapidly extinguished due to improperly maintained extinguishers.

Findings include:

On April 19, 2011 between 12:30 p.m. and 2:30 p.m., fire extinguishers located throughout the facility were observed to not have any six year maintenance collars or six year maintenance labels affixed to the extinguishers. All extinguishers were observed to have a date of manufacture of 1992 or 1996. One fire extinguisher in the medical/surgical wing was observed to have a six year maintenance collar with no dates punched which was cut and placed on the fire extinguisher below the valve stem assembly, but the required six year label was dated 1993.