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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 18.3.6.3. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.


Finding is:

A. At 11:25 on 6/11/13 it was observed that the pair of corridor doors from the Gymnasium located on the main floor, had a 1/2" gap between the doors as not to be considered resistant to the passage of smoke to comply with 18.3.6.3.2 and CMS S&C 07-18.

Based on random observation, while accompanied by the Director of Engineering, the surveyor finds that corridor vision panels within fire resistance rated walls are not tested assemblies to comply with NFPA 80 1999, 13-2.2. Failure to maintain corridor walls fire resistance rating in accordance with NFPA 101 could allow smoke to spread from room to room in a fire emergency.

Findings include:

A. On 6-10 and 11 at 2:00pm Vision panels within fire resistant corridor wall assemblies were observed (per the facility Life Safety floor plans dated 2006) which do not carry an indication per the fire resistant rating. Numerous vision panels are comprised of polycarbonate. Locations observed:

1. Second floor day room and multipurpose room adjacent to the nurse station.

2. Third floor day room and multipurpose room adjacent to the nurse station.

Based on random observation during the survey walk-through while accompanied by the Director of Engineering, hazardous areas do not comply with 18.3.2.1 and 18.3.6.3.4. These areas/rooms do not provide a continuous separation from adjacent spaces or egress corridors. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Locations and conditions observed are as follows:

A. On 6/11/13 at 11:54am the Second and Third floor former smoking rooms contain storage in quantities deemed hazardous. These rooms are enclosed on three sides and open to the exterior on one wall through the use of open air grilles. This enclosure does not comply with 18.3.2.1 for a complete enclosure. And does not comply with 8.2.2.2 for a 1-hour fire rated enclosure.

B. On 6/11/13 between 9:00am and 11:30am it was observed that the fire rating labels on the doors of designated hazardous areas were painted which did not allow confirmation of the opening protection required by NFPA 101-2000, 8.2.3.2.1.
Example locations observed:

1. main floor electrical closets adjacent to the conference rooms

2. main floor purchasing/mail room.

3. second and third floor soiled utility rooms

4. second and third floor clean utility rooms

C. On 6/11/13 at 11:30am second floor laundry room contains a pipe penetration through the east wall behind the washer/dryer units which is not sealed against the passage of smoke and fire.

Based on random observation during the survey walk through, while accompanied by engineering staff, not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This condition may affect patients, staff and visitors on the upper floors from a safe means of egress during a fire/smoke event.

Findings include:

A.. 6/11/13, at 9:15 am exit stair doors do not maintain the required fire resistant rating for the exit stair to comply with 18.3.1.1, 8.2.5.4 and 8.2.3.2.3.1. Stair doors were observed which lack a label indicating the fire resistance rating of the door. Locations observed, North, South, East and West stair each floor level.

B. 6/11/13, at 9:15 am exit stair doors do not maintain the required fire resistant rating for the exit stair to comply with 18.3.1.1, 8.2.5.4 and 8.2.3.2.3.1. Stair doors were observed which have the fire resistance of the door assembly compromised due to punctures and holes. Example location observed West Stair second floor.

Based on observation during the survey walk-through while accompanied by the Director of Engineering, not all exit stairs are constructed in accordance with the requirements of 19.2.2.3 & 7.2.2. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by impeding the use of the stairs during building exiting.

Findings include:

A. On 6/11 at 9:15am was observed that stair enclosures were being used as storage stations for housekeeping equipment/misc supplies in noncompliance with 7.1.3.2.3. Locations include:

1. West Stair (containing file cabinets, boxes)

2. South Stair (containing Christmas decorations, file cabinets)

3. East Stair (containing file cabinets)

Based on observation during the survey walk-through while accompanied by the Director of Engineering, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 18.2.1 and 7.1. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 10:25am on 6/11/13 it was observed that the corridor door to the purchasing department located on the main level was equipped with a hook and eye hold open device. The hardware installation constitutes a second releasing operation to operate the the door when used in combination with latching hardware in noncompliance with 7.2.1.5.4.

B. At 11:40am on 6/11/13 it was observed that a pair of cross corridor doors from the Cafeteria located on the main level were equipped with manual hold open devices which prevent the doors from closing under emergency conditions. The hardware installation does not comply with 18.3.6.1.

Based on random observation during the survey walk, while accompanied by facility staff, failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors. The installation does not comply with NFPA 13 1999.

Findings include:

A. The surveyor finds on the morning of 6/11/13, while in the company of the facility's Director of Engineering, the facility failed to provide compliant fire sprinkler protection in the following areas:

1. The nurse stations located on 2nd and 3rd floor: the sprinkler heads are installed in bottom of the soffits which are more than 12 inches below the ceiling surfaces. (NFPA 13, 1999, 5-6.4.1)

2. The former smoking rooms on 2nd and 3rd floors (north and south wings) now being used for storage do not have sprinkler heads. (NFPA 13, 1999, 5-1)

3. The main electrical switch gear room has a two hour rated enclosure and does not have sprinkler protection which is allowed by NFPA 13, 1999, 5-13.11 however the room contains stored items which is not allowed.

4. The electrical closet located at the 1st floor staff corridor have had the door latching hardware handles removed leaving holes in the door surfaces compromising the two hour enclosure rating for the closet enclosure. (NFPA 13, 1999, 5-13.11)


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B. On 6/10 at 2:45pm Sprinklered rooms are missing ceiling tiles or have holes in the ceiling which compromises the activation of the sprinkler heads under fire and smoke conditions and therefore does not comply with NFPA 13 1999 5-5.1
Locations include:

1. Third floor Patient Belonging room (deemed as storage)

2. Second floor Patient Belonging room (deemed as storage)

Based on random observation during the survey walk-through while accompanied by the Director of Facilities, the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised if normal power is lost and the emergency generator will not start.

Findings include:

A. On 6/11/13 at 10:00am the generator was not equipped with a battery heater to meet the requirements of NFPA-110, Section 3-3.1.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 18.3.6.3. This deficiency could affect all patients in the locations as well as any staff and visitors present, by allowing smoke to pass from one side of the corridor wall to the other; either compromising the building's exit access corridors or the rooms occupied.


Finding is:

A. At 11:25 on 6/11/13 it was observed that the pair of corridor doors from the Gymnasium located on the main floor, had a 1/2" gap between the doors as not to be considered resistant to the passage of smoke to comply with 18.3.6.3.2 and CMS S&C 07-18.

Based on random observation, while accompanied by the Director of Engineering, the surveyor finds that corridor vision panels within fire resistance rated walls are not tested assemblies to comply with NFPA 80 1999, 13-2.2. Failure to maintain corridor walls fire resistance rating in accordance with NFPA 101 could allow smoke to spread from room to room in a fire emergency.

Findings include:

A. On 6-10 and 11 at 2:00pm Vision panels within fire resistant corridor wall assemblies were observed (per the facility Life Safety floor plans dated 2006) which do not carry an indication per the fire resistant rating. Numerous vision panels are comprised of polycarbonate. Locations observed:

1. Second floor day room and multipurpose room adjacent to the nurse station.

2. Third floor day room and multipurpose room adjacent to the nurse station.

Based on random observation during the survey walk-through while accompanied by the Director of Engineering, hazardous areas do not comply with 18.3.2.1 and 18.3.6.3.4. These areas/rooms do not provide a continuous separation from adjacent spaces or egress corridors. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Locations and conditions observed are as follows:

A. On 6/11/13 at 11:54am the Second and Third floor former smoking rooms contain storage in quantities deemed hazardous. These rooms are enclosed on three sides and open to the exterior on one wall through the use of open air grilles. This enclosure does not comply with 18.3.2.1 for a complete enclosure. And does not comply with 8.2.2.2 for a 1-hour fire rated enclosure.

B. On 6/11/13 between 9:00am and 11:30am it was observed that the fire rating labels on the doors of designated hazardous areas were painted which did not allow confirmation of the opening protection required by NFPA 101-2000, 8.2.3.2.1.
Example locations observed:

1. main floor electrical closets adjacent to the conference rooms

2. main floor purchasing/mail room.

3. second and third floor soiled utility rooms

4. second and third floor clean utility rooms

C. On 6/11/13 at 11:30am second floor laundry room contains a pipe penetration through the east wall behind the washer/dryer units which is not sealed against the passage of smoke and fire.

Based on random observation during the survey walk through, while accompanied by engineering staff, not all designated exit stair enclosures provide a protected means of egress to an exit discharge. This condition may affect patients, staff and visitors on the upper floors from a safe means of egress during a fire/smoke event.

Findings include:

A.. 6/11/13, at 9:15 am exit stair doors do not maintain the required fire resistant rating for the exit stair to comply with 18.3.1.1, 8.2.5.4 and 8.2.3.2.3.1. Stair doors were observed which lack a label indicating the fire resistance rating of the door. Locations observed, North, South, East and West stair each floor level.

B. 6/11/13, at 9:15 am exit stair doors do not maintain the required fire resistant rating for the exit stair to comply with 18.3.1.1, 8.2.5.4 and 8.2.3.2.3.1. Stair doors were observed which have the fire resistance of the door assembly compromised due to punctures and holes. Example location observed West Stair second floor.

Based on observation during the survey walk-through while accompanied by the Director of Engineering, not all exit stairs are constructed in accordance with the requirements of 19.2.2.3 & 7.2.2. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by impeding the use of the stairs during building exiting.

Findings include:

A. On 6/11 at 9:15am was observed that stair enclosures were being used as storage stations for housekeeping equipment/misc supplies in noncompliance with 7.1.3.2.3. Locations include:

1. West Stair (containing file cabinets, boxes)

2. South Stair (containing Christmas decorations, file cabinets)

3. East Stair (containing file cabinets)

Based on observation during the survey walk-through while accompanied by the Director of Engineering, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 18.2.1 and 7.1. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 10:25am on 6/11/13 it was observed that the corridor door to the purchasing department located on the main level was equipped with a hook and eye hold open device. The hardware installation constitutes a second releasing operation to operate the the door when used in combination with latching hardware in noncompliance with 7.2.1.5.4.

B. At 11:40am on 6/11/13 it was observed that a pair of cross corridor doors from the Cafeteria located on the main level were equipped with manual hold open devices which prevent the doors from closing under emergency conditions. The hardware installation does not comply with 18.3.6.1.

Based on random observation during the survey walk, while accompanied by facility staff, failure to install and maintain the sprinkler system could result in failure of the sprinkler system and delayed response during a fire event, which could affect patients, staff and visitors. The installation does not comply with NFPA 13 1999.

Findings include:

A. The surveyor finds on the morning of 6/11/13, while in the company of the facility's Director of Engineering, the facility failed to provide compliant fire sprinkler protection in the following areas:

1. The nurse stations located on 2nd and 3rd floor: the sprinkler heads are installed in bottom of the soffits which are more than 12 inches below the ceiling surfaces. (NFPA 13, 1999, 5-6.4.1)

2. The former smoking rooms on 2nd and 3rd floors (north and south wings) now being used for storage do not have sprinkler heads. (NFPA 13, 1999, 5-1)

3. The main electrical switch gear room has a two hour rated enclosure and does not have sprinkler protection which is allowed by NFPA 13, 1999, 5-13.11 however the room contains stored items which is not allowed.

4. The electrical closet located at the 1st floor staff corridor have had the door latching hardware handles removed leaving holes in the door surfaces compromising the two hour enclosure rating for the closet enclosure. (NFPA 13, 1999, 5-13.11)


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B. On 6/10 at 2:45pm Sprinklered rooms are missing ceiling tiles or have holes in the ceiling which compromises the activation of the sprinkler heads under fire and smoke conditions and therefore does not comply with NFPA 13 1999 5-5.1
Locations include:

1. Third floor Patient Belonging room (deemed as storage)

2. Second floor Patient Belonging room (deemed as storage)

Based on random observation during the survey walk-through while accompanied by the Director of Facilities, the generator equipment does not meet all requirements of NFPA-110. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised if normal power is lost and the emergency generator will not start.

Findings include:

A. On 6/11/13 at 10:00am the generator was not equipped with a battery heater to meet the requirements of NFPA-110, Section 3-3.1.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.