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Based on observation and interview, the facility did not provide and maintain the required building construction type. This deficiency occurred in 3 of the 15 smoke compartments, and had the potential to affect 10 of the 35 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/4/2011 at 10:30 am surveyor #12187 observed in the #8 smoke compartment on the 3rd floor in the penthouse 'well', that there were penetration(s) through the floor that were not fire stopped according to a UL design standard. The deficiency included a 3 foot long, 1 1/2 inch diameter pipe that was in the wall separating the penthouse stairs from the third floor. This pipe was in place of the dry wall. This wall is required to be one hour fire rated. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/4/2011 at 10:45 am surveyor #12187 observed in the #11 smoke compartment on the 1st floor in the closet next to room 1344, that there were penetration(s) through the floor that were not fire stopped according to a UL design standard. There are 4 pipes passing through 1st and 2nd floor that do not have any fire caulking. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation, interview, and a review of facility flame spread documents, the facility did not provide room finishes that had rated wall finishes. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 1/4/2011 at 8:01 am surveyor #12187 observed in the #5 smoke compartment on the 2nd floor in the 214, that the facility could not confirm the wall had an appropriate rating. The room wall was finished with a 3' X 8' wood paneling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide corridor separation doors that had smoke-tight seals at meeting edges, smoke-tight corridor frames, and positive-latching hardware. This deficiency occurred in 3 of the 15 smoke compartments, and had the potential to affect 32 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/3/2011 at 1:50 pm surveyor #12187 observed in the #1 smoke compartment on the 3rd floor in the all four ICU rooms, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The gap was 3/16 of an inch on the corridor side. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/3/2011 at 3:40 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor in the room 2143, that the room had double corridor doors with a gap greater than 1/8" 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 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

3. On 1/4/2011 at 9:53 am surveyor #12187 observed in the #7 smoke compartment on the 3rd floor in the Coordinator office for geriatric unit, that the door had a frame that would not resist the passage of smoke because the door did not abut to the door frame. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

4. On 1/4/2011 at 10:15 am surveyor #12187 observed in the #7 smoke compartment on the 3rd floor in the old bathroom of the geriatric unit, that the door had a frame that would not resist the passage of smoke because the door did not abut to the door frame. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

5. On 1/3/2011 at 3:17 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor in the surgery suite, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations, and rated wall construction. This deficiency occurred in 4 of the 15 smoke compartments, and had the potential to affect 35 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/3/2011 at 12:04 pm surveyor #12187 observed in the #1 & #2 smoke compartment on the 3rd floor near the ICU, that penetrations were not sealed according to approved UL designs. The deficiency included one inch diameter penetration by a cable. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/4/2011 at 10:20 am surveyor #12187 observed in the #7 & #8 smoke compartment on the 3rd floor in the smoke barrier wall in the geriatric unit, that penetrations were not sealed according to approved UL designs. The deficiency included a 1 inch conduit that was not fire caulked. In addition, the screws on the walls were not mudded. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

3. On 1/3/2011 at 11:55 am surveyor #12187 observed in the #1 & #2 smoke compartment on the 3rd floor in the corridor, near shower room, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the top of the wall had a 1 inch gap of drywall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not enclose hazardous rooms that had closers on all doors. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 1/5/2011 at 8:45 am surveyor #12187 observed in the #10 smoke compartment on the 1st floor in the room 1220, that the door would not self-close because there is no door closer. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not enclose hazardous rooms that had rated doors, and taped joints on rated walls . This deficiency occurred in 3 of the 15 smoke compartments, and had the potential to affect 35 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/4/2011 at 10:05 am surveyor #12187 observed in the #7 smoke compartment on the 3rd floor in the geriatric unit clean linen room, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. Two full linen carts and plastic material was stored in the room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/3/2011 at 1:35 pm surveyor #12187 observed in the #2 smoke compartment on the 3rd floor in the equipment room 3094, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all UL designs for rated walls. It contained combustibles such as bags of foam, lamb wool, and storage of combustible material in plastic bags. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

3. On 1/3/2011 at 2:00 pm surveyor #12187 observed in the #1 smoke compartment on the 3rd floor in the equipment (storage) room 3057, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all UL designs for rated walls. The equipment being stored in the room is combustible. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

4. On 1/3/2011 at 2:10 pm surveyor #12187 observed in the #1 smoke compartment on the 3rd floor in the Pharmacy room, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all UL designs for rated walls. 8 Metal shelving totally full of open cardboard containers (1 inch wide by 8 inch deep by 6 inch tall) that have individual plastic wrapped pills or other items. There also was 8 pints of 70% alcohol in plastic bottles on the shelves. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide egress paths with sufficient headroom. This deficiency occurred in 2 of the 15 smoke compartments, and had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/5/2011 at 10:00 am surveyor #12187 observed in the #14 smoke compartment on the basement floor in the print shop, room L146, that the headroom was 6 feet beneath lights and sprinklers. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/5/2011 at 1:00 pm surveyor #12187 observed in the #13 smoke compartment on the basement floor in the Bryant center, that the headroom was 6 feet 6 inches through the 4 doors. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not ensure corridor doors had the required clear width of doors. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 1 staff.

FINDINGS INCLUDE:
On 1/4/2011 at 9:53 am surveyor #12187 observed in the #7 smoke compartment on the 3rd floor in the Coordinator office for geriatric unit, that the door in the corridor was narrower than the required 32" minimum clear width. The door is prohibited from fully opening. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.3.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide and maintain emergency illumination of exit and directional signs. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 7 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 1/3/2011 at 2:55 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor in the corridor going into surgery, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near room 2146. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements necessary to ensure staff are trained on life safety procedures. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 1/5/2011 at 10:48 am surveyor #12187 observed that staff were not familiar with their responsibilities in the event of a fire, including staff X , a cook, who did not know where the pull station for the grease hood was located. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.1.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, that included no obstructions near the sprinkler. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 0 of the 35 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 1/5/2011 at 9:30 am surveyor #12187 observed in the #15 smoke compartment on the basement floor in the Purchasing storage room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included boxes on 5 storage carts. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. This deficiency occurred in 3 of the 15 smoke compartments, and had the potential to affect 4 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/3/2011 at 2:46 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor in the electric room 2160, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The corridor walls are not built to one hour protection. This observed situation was not compliant with NFPA 101 (2000 edition). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/5/2011 at 9:00 am surveyor #12187 observed in the #10 smoke compartment on the 2nd floor in the room 1245, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side obstructing item . The obstruction included a soffit that prevents water from reaching the floor. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

3. On 1/5/2011 at 8:31 am surveyor #12187 observed in the #10 smoke compartment on the 1st floor in the room 1209, that a sprinkler was located five feet from another sprinkler. Sprinklers cannot be closer to each other than the minimum required separation distance of 60" or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

4. On 1/4/2011 at 11:00 am surveyor #12187 observed in the #11 smoke compartment on the 1st floor in the room 1305, that a sprinkler was located 10 feet between sprinklers Sprinklers cannot be farther from each other than the maximum required separation distance of 15' for standard discharge heads or farther than 7-1/2' from a wall. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation, record review, and interview, the facility did not provide and maintain portable fire extinguishers as required. This deficiency had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 1/3/2011 at 11:30 am surveyor #12187 observed during a review of document, that fire extinguishers were not inspected since May 2007 This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5.6, 9.7.4.1 and NFPA 10. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A. This deficiency occurred in 2 of the 15 smoke compartments, and had the potential to affect 35 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/4/2011 at 10:15 am surveyor #12187 observed in the #7 smoke compartment on the 3rd floor in the old bathroom of the geriatric unit, that airflow between the corridor and this room was not neutral. The air flow is from the corridor into the old bathroom exhaust through a transfer grill. The old bathroom is not being used as a bathroom. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/3/2011 at 11:45 am surveyor #12187 observed in the penthouse, that the smoke detector for the supply duct was down stream of the air filters, but it was not ahead of any branch connection in the supply that had more than 2000 CFM. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility failed to keep corridors free of materials. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 3 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 1/3/2011 at 2:45 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor , that items were stored in the exit access pathway, including a cart full of scrub suits, hair nets, and booties to dress for surgery. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 (exception 6), and 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation), and staff E, (RN).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the amount of trash in a given area. This deficiency occurred in 2 of the 15 smoke compartments, and had the potential to affect 4 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/3/2011 at 3:00 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor in the OR 3, that mobile collection receptacles exceeded the 32 gallon maximum size per 64 square feet when located outside of a hazardous area. Two 32 gallon trash containers and two 25 gallon trash containers were stored in one 64 square foot area and three 25 gallon trash containers were stored in another 64 square foot area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation), and staff E.

2. On 1/3/2011 at 3:23 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor between OR 2 and OR 3, that mobile collection receptacles exceeded the 32 gallon maximum size per 64 square foot area when located outside of a hazardous area. Three 32 gallon trash containers and three 25 gallon trash containers were stored in one 64 square foot area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation), and staff E.

3. On 1/5/2011 at 9:19 am surveyor #12187 observed in the #9 smoke compartment on the 1st floor in the ER 3, that mobile collection receptacles exceeded the 32 gallon maximum size per 64 square foot area when located outside of a hazardous area. Two 32 gallon trash containers were stored in one 64 square foot area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

4. On 1/5/2011 at 9:20 am surveyor #12187 observed in the #9 smoke compartment on the 1st floor in the ER 4, that mobile collection receptacles exceeded the 32 gallon maximum size per 64 square foot area when located outside of a hazardous area. Two 32 gallon trash containers and two 25 gallon trash containers were stored in one 64 square foot area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 6 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 1/4/2011 at 7:39 am surveyor #12187 observed in the #4 smoke compartment on the 2nd floor in the 2240 Cardiac rehab, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included the oxygen shut off valve is in the same room as the oxygen supply outlets. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), Chap 4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation, record review, and interview, the facility did not provide proper maintenance to a Type I essential electrical system. This deficiency occurred in all of the 15 smoke compartments that have critical care recepticles, and had the potential to affect 35 of the 35 patients that the facility was licensed to server.

FINDINGS INCLUDE:
On 1/4/2011 at 3:00 pm surveyor #12187 during a record review, observed that the facility did not have records of testing patient care receptables. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.9.1 and NFPA 99 (1999 edition), 3-3.3.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation, the facility failed to provide unoccupied rooms from opening onto stairs or exit passageways and failed to provide a barrier to prevent people from going beyond the level of exit discharge.

FINDINGS INCLUDE:
1) On January 4, 2011 at 13:35 pm, surveyor # 12187 observed in smoke compartment #9 on the first floor by the stairs (exit stair in the 1956 building) that the belt room (LL326, an unoccupied room) opens into the stairwell enclosure. This is not permitted in the Life Safety Code, NFPA 101, 2000, 7.1.3.2.(d)1 which state "Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure." The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2) On January 4, 2011 at 11:35 am, surveyor # 12187 observed in smoke compartment #10, on the first floor by the stairs (by the ER) that stairs continue more than one-half story beyond the level of discharge; and are not interrupted at the level of exit discharge by partitions, doors or other effective means as required by NFPA 101, 2000 7.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

NFPA 101, 2000 edition, 7.2.1.5.4 states " A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm) above the finished floor. Doors shall be operable with not more than one releasing operation " .

Based on observation and interview, the facility did not maintain an exit door with the proper exit hardware. This deficiency would affect 10 outpatients in the facility on the day of the survey.FINDINGS INCLUDE: It was observed for the west exterior exit door for the suite, that there are two motions to get out of the exit door; one to unlatch the door and other to release the dead bolt. This deficiency was observed and verified by surveyor 12187, Staff H, Director of Environmental Services on January 4, 2009 at 3 pm.

NFPA 101, 2000 edition, 7.7.1 states "Exits shall terminate directly at a public way or at an exterior exit exit discharge. Yard, court, open spaces, or other portions of the exit discharge shall be of required width and size to provide all ocupants with a safe access to a public way."

Based on observation and interview, the facility did not maintain the exit discharge with a safe access to a public way. This deficiency would affect 10 outpatients in the facility on the day of the survey.FINDINGS INCLUDE: It was observed that the exterior exit door for the suite was only an 8 by 8 foot stupe. The snow was not removed across the grass to a public way. The grass will turn to mud with heavy rain when the ground thaws. This deficiency was observed and verified by Staff H, Director of Environmental Services on January 4, 2009 at 2:30 pm.

Based on observation, interview and a review of documents, the facility did not test the emergency electrical generator in accordance with requirements. This deficiency occurred in all of the 15 smoke compartments, and had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/5/2011 at 11 am surveyor #12187 observed in the mechanical room for the 1975 and 1956 generators, that no alarm went to an occupied location when the generator had over-speed, low lube press, over charging, or excess temperature. This observed situation was not compliant with NFPA 110 (1999 edition), 6-4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/3/2011 at 3:00 pm surveyor #12187 observed during a review of facility documents, that the facility did not exercise the automatic transfer switch on a monthly basis. The facility does not have documentation that the 1975 generator will start under load within 10 seconds of a power loss. This observed situation was not compliant with NFPA 99 (1999 edition), 3-5.4.1.1, and NFPA 110 (1999 edition), 6-4.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

3. On 1/3/2011 at 3:00 pm surveyor #12187 observed that during a review of facility documents, there was no weekly visual inspections of the generator fluids, and no general condition of the generators were recorded. There was no weekly inspections for any of the 3 generators. This observed situation was not compliant with NFPA 110 (1999 edition), 6-3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide a Type I essential electrical system that was properly divided. This deficiency occurred in 4 of the 15 smoke compartments, and had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 1/5/2011 at 8:06 am surveyor #12187 observed that the type 1 emergency electrical system did not have the critical care outlets identified in the 1975 building. In addition, in the critical care areas, it could not be determined if the critical care outlets were on two different transfer switches. This observed situation was not compliant with NFPA 99 (1999 edition) 3-4.2.2.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide and maintain a safe electrical system. This deficiency occurred in 2 of the 15 smoke compartments, and had the potential to affect 10 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/5/2011 at 9:35 am surveyor #12187 observed in the #13 smoke compartment on the basement floor in the Purchasing storage room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a microwave oven and a toaster. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/4/2011 at 9:55 am surveyor #12187 observed in the #7 smoke compartment on the 3rd floor in the Nurse station for geriatric unit, that a flexible cord was used in a manner that is not permitted by the code. The cord passed underneath a door opening on the floor. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide alcohol based hand rub dispensers that were installed and located as permitted by the code. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 22 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 1/3/2011 at 1:20 pm surveyor #12187 observed in the #2 smoke compartment on the 3rd floor in the south nurse station, that an alcohol based hand rub (ABHR) dispenser was installed in a corridor that was 8 feet wide, had a capacity of 1.2 liters, and was located 2 inches from an outlet/switch which could arc. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.7 and CFR 403.744. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide and maintain the required building construction type. This deficiency occurred in 3 of the 15 smoke compartments, and had the potential to affect 10 of the 35 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/4/2011 at 10:30 am surveyor #12187 observed in the #8 smoke compartment on the 3rd floor in the penthouse 'well', that there were penetration(s) through the floor that were not fire stopped according to a UL design standard. The deficiency included a 3 foot long, 1 1/2 inch diameter pipe that was in the wall separating the penthouse stairs from the third floor. This pipe was in place of the dry wall. This wall is required to be one hour fire rated. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/4/2011 at 10:45 am surveyor #12187 observed in the #11 smoke compartment on the 1st floor in the closet next to room 1344, that there were penetration(s) through the floor that were not fire stopped according to a UL design standard. There are 4 pipes passing through 1st and 2nd floor that do not have any fire caulking. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation, interview, and a review of facility flame spread documents, the facility did not provide room finishes that had rated wall finishes. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 1/4/2011 at 8:01 am surveyor #12187 observed in the #5 smoke compartment on the 2nd floor in the 214, that the facility could not confirm the wall had an appropriate rating. The room wall was finished with a 3' X 8' wood paneling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide corridor separation doors that had smoke-tight seals at meeting edges, smoke-tight corridor frames, and positive-latching hardware. This deficiency occurred in 3 of the 15 smoke compartments, and had the potential to affect 32 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/3/2011 at 1:50 pm surveyor #12187 observed in the #1 smoke compartment on the 3rd floor in the all four ICU rooms, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The gap was 3/16 of an inch on the corridor side. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/3/2011 at 3:40 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor in the room 2143, that the room had double corridor doors with a gap greater than 1/8" 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 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

3. On 1/4/2011 at 9:53 am surveyor #12187 observed in the #7 smoke compartment on the 3rd floor in the Coordinator office for geriatric unit, that the door had a frame that would not resist the passage of smoke because the door did not abut to the door frame. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

4. On 1/4/2011 at 10:15 am surveyor #12187 observed in the #7 smoke compartment on the 3rd floor in the old bathroom of the geriatric unit, that the door had a frame that would not resist the passage of smoke because the door did not abut to the door frame. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

5. On 1/3/2011 at 3:17 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor in the surgery suite, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations, and rated wall construction. This deficiency occurred in 4 of the 15 smoke compartments, and had the potential to affect 35 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/3/2011 at 12:04 pm surveyor #12187 observed in the #1 & #2 smoke compartment on the 3rd floor near the ICU, that penetrations were not sealed according to approved UL designs. The deficiency included one inch diameter penetration by a cable. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/4/2011 at 10:20 am surveyor #12187 observed in the #7 & #8 smoke compartment on the 3rd floor in the smoke barrier wall in the geriatric unit, that penetrations were not sealed according to approved UL designs. The deficiency included a 1 inch conduit that was not fire caulked. In addition, the screws on the walls were not mudded. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

3. On 1/3/2011 at 11:55 am surveyor #12187 observed in the #1 & #2 smoke compartment on the 3rd floor in the corridor, near shower room, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the top of the wall had a 1 inch gap of drywall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not enclose hazardous rooms that had closers on all doors. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 1/5/2011 at 8:45 am surveyor #12187 observed in the #10 smoke compartment on the 1st floor in the room 1220, that the door would not self-close because there is no door closer. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not enclose hazardous rooms that had rated doors, and taped joints on rated walls . This deficiency occurred in 3 of the 15 smoke compartments, and had the potential to affect 35 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/4/2011 at 10:05 am surveyor #12187 observed in the #7 smoke compartment on the 3rd floor in the geriatric unit clean linen room, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. Two full linen carts and plastic material was stored in the room. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/3/2011 at 1:35 pm surveyor #12187 observed in the #2 smoke compartment on the 3rd floor in the equipment room 3094, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all UL designs for rated walls. It contained combustibles such as bags of foam, lamb wool, and storage of combustible material in plastic bags. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

3. On 1/3/2011 at 2:00 pm surveyor #12187 observed in the #1 smoke compartment on the 3rd floor in the equipment (storage) room 3057, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all UL designs for rated walls. The equipment being stored in the room is combustible. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

4. On 1/3/2011 at 2:10 pm surveyor #12187 observed in the #1 smoke compartment on the 3rd floor in the Pharmacy room, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all UL designs for rated walls. 8 Metal shelving totally full of open cardboard containers (1 inch wide by 8 inch deep by 6 inch tall) that have individual plastic wrapped pills or other items. There also was 8 pints of 70% alcohol in plastic bottles on the shelves. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide egress paths with sufficient headroom. This deficiency occurred in 2 of the 15 smoke compartments, and had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/5/2011 at 10:00 am surveyor #12187 observed in the #14 smoke compartment on the basement floor in the print shop, room L146, that the headroom was 6 feet beneath lights and sprinklers. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/5/2011 at 1:00 pm surveyor #12187 observed in the #13 smoke compartment on the basement floor in the Bryant center, that the headroom was 6 feet 6 inches through the 4 doors. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not ensure corridor doors had the required clear width of doors. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 1 staff.

FINDINGS INCLUDE:
On 1/4/2011 at 9:53 am surveyor #12187 observed in the #7 smoke compartment on the 3rd floor in the Coordinator office for geriatric unit, that the door in the corridor was narrower than the required 32" minimum clear width. The door is prohibited from fully opening. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.3.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide and maintain emergency illumination of exit and directional signs. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 7 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 1/3/2011 at 2:55 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor in the corridor going into surgery, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near room 2146. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not maintain a written evacuation plan that contained all the elements necessary to ensure staff are trained on life safety procedures. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 1/5/2011 at 10:48 am surveyor #12187 observed that staff were not familiar with their responsibilities in the event of a fire, including staff X , a cook, who did not know where the pull station for the grease hood was located. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.1.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, that included no obstructions near the sprinkler. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 0 of the 35 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 1/5/2011 at 9:30 am surveyor #12187 observed in the #15 smoke compartment on the basement floor in the Purchasing storage room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included boxes on 5 storage carts. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. This deficiency occurred in 3 of the 15 smoke compartments, and had the potential to affect 4 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/3/2011 at 2:46 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor in the electric room 2160, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The corridor walls are not built to one hour protection. This observed situation was not compliant with NFPA 101 (2000 edition). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/5/2011 at 9:00 am surveyor #12187 observed in the #10 smoke compartment on the 2nd floor in the room 1245, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side obstructing item . The obstruction included a soffit that prevents water from reaching the floor. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

3. On 1/5/2011 at 8:31 am surveyor #12187 observed in the #10 smoke compartment on the 1st floor in the room 1209, that a sprinkler was located five feet from another sprinkler. Sprinklers cannot be closer to each other than the minimum required separation distance of 60" or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

4. On 1/4/2011 at 11:00 am surveyor #12187 observed in the #11 smoke compartment on the 1st floor in the room 1305, that a sprinkler was located 10 feet between sprinklers Sprinklers cannot be farther from each other than the maximum required separation distance of 15' for standard discharge heads or farther than 7-1/2' from a wall. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation, record review, and interview, the facility did not provide and maintain portable fire extinguishers as required. This deficiency had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 1/3/2011 at 11:30 am surveyor #12187 observed during a review of document, that fire extinguishers were not inspected since May 2007 This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5.6, 9.7.4.1 and NFPA 10. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A. This deficiency occurred in 2 of the 15 smoke compartments, and had the potential to affect 35 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/4/2011 at 10:15 am surveyor #12187 observed in the #7 smoke compartment on the 3rd floor in the old bathroom of the geriatric unit, that airflow between the corridor and this room was not neutral. The air flow is from the corridor into the old bathroom exhaust through a transfer grill. The old bathroom is not being used as a bathroom. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/3/2011 at 11:45 am surveyor #12187 observed in the penthouse, that the smoke detector for the supply duct was down stream of the air filters, but it was not ahead of any branch connection in the supply that had more than 2000 CFM. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility failed to keep corridors free of materials. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 3 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 1/3/2011 at 2:45 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor , that items were stored in the exit access pathway, including a cart full of scrub suits, hair nets, and booties to dress for surgery. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 (exception 6), and 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation), and staff E, (RN).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the amount of trash in a given area. This deficiency occurred in 2 of the 15 smoke compartments, and had the potential to affect 4 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/3/2011 at 3:00 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor in the OR 3, that mobile collection receptacles exceeded the 32 gallon maximum size per 64 square feet when located outside of a hazardous area. Two 32 gallon trash containers and two 25 gallon trash containers were stored in one 64 square foot area and three 25 gallon trash containers were stored in another 64 square foot area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation), and staff E.

2. On 1/3/2011 at 3:23 pm surveyor #12187 observed in the #3 smoke compartment on the 2nd floor between OR 2 and OR 3, that mobile collection receptacles exceeded the 32 gallon maximum size per 64 square foot area when located outside of a hazardous area. Three 32 gallon trash containers and three 25 gallon trash containers were stored in one 64 square foot area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation), and staff E.

3. On 1/5/2011 at 9:19 am surveyor #12187 observed in the #9 smoke compartment on the 1st floor in the ER 3, that mobile collection receptacles exceeded the 32 gallon maximum size per 64 square foot area when located outside of a hazardous area. Two 32 gallon trash containers were stored in one 64 square foot area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

4. On 1/5/2011 at 9:20 am surveyor #12187 observed in the #9 smoke compartment on the 1st floor in the ER 4, that mobile collection receptacles exceeded the 32 gallon maximum size per 64 square foot area when located outside of a hazardous area. Two 32 gallon trash containers and two 25 gallon trash containers were stored in one 64 square foot area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 6 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 1/4/2011 at 7:39 am surveyor #12187 observed in the #4 smoke compartment on the 2nd floor in the 2240 Cardiac rehab, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included the oxygen shut off valve is in the same room as the oxygen supply outlets. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), Chap 4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation, record review, and interview, the facility did not provide proper maintenance to a Type I essential electrical system. This deficiency occurred in all of the 15 smoke compartments that have critical care recepticles, and had the potential to affect 35 of the 35 patients that the facility was licensed to server.

FINDINGS INCLUDE:
On 1/4/2011 at 3:00 pm surveyor #12187 during a record review, observed that the facility did not have records of testing patient care receptables. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.9.1 and NFPA 99 (1999 edition), 3-3.3.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation, the facility failed to provide unoccupied rooms from opening onto stairs or exit passageways and failed to provide a barrier to prevent people from going beyond the level of exit discharge.

FINDINGS INCLUDE:
1) On January 4, 2011 at 13:35 pm, surveyor # 12187 observed in smoke compartment #9 on the first floor by the stairs (exit stair in the 1956 building) that the belt room (LL326, an unoccupied room) opens into the stairwell enclosure. This is not permitted in the Life Safety Code, NFPA 101, 2000, 7.1.3.2.(d)1 which state "Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure." The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2) On January 4, 2011 at 11:35 am, surveyor # 12187 observed in smoke compartment #10, on the first floor by the stairs (by the ER) that stairs continue more than one-half story beyond the level of discharge; and are not interrupted at the level of exit discharge by partitions, doors or other effective means as required by NFPA 101, 2000 7.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

NFPA 101, 2000 edition, 7.2.1.5.4 states " A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm) above the finished floor. Doors shall be operable with not more than one releasing operation " .

Based on observation and interview, the facility did not maintain an exit door with the proper exit hardware. This deficiency would affect 10 outpatients in the facility on the day of the survey.FINDINGS INCLUDE: It was observed for the west exterior exit door for the suite, that there are two motions to get out of the exit door; one to unlatch the door and other to release the dead bolt. This deficiency was observed and verified by surveyor 12187, Staff H, Director of Environmental Services on January 4, 2009 at 3 pm.

NFPA 101, 2000 edition, 7.7.1 states "Exits shall terminate directly at a public way or at an exterior exit exit discharge. Yard, court, open spaces, or other portions of the exit discharge shall be of required width and size to provide all ocupants with a safe access to a public way."

Based on observation and interview, the facility did not maintain the exit discharge with a safe access to a public way. This deficiency would affect 10 outpatients in the facility on the day of the survey.FINDINGS INCLUDE: It was observed that the exterior exit door for the suite was only an 8 by 8 foot stupe. The snow was not removed across the grass to a public way. The grass will turn to mud with heavy rain when the ground thaws. This deficiency was observed and verified by Staff H, Director of Environmental Services on January 4, 2009 at 2:30 pm.

Based on observation, interview and a review of documents, the facility did not test the emergency electrical generator in accordance with requirements. This deficiency occurred in all of the 15 smoke compartments, and had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/5/2011 at 11 am surveyor #12187 observed in the mechanical room for the 1975 and 1956 generators, that no alarm went to an occupied location when the generator had over-speed, low lube press, over charging, or excess temperature. This observed situation was not compliant with NFPA 110 (1999 edition), 6-4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/3/2011 at 3:00 pm surveyor #12187 observed during a review of facility documents, that the facility did not exercise the automatic transfer switch on a monthly basis. The facility does not have documentation that the 1975 generator will start under load within 10 seconds of a power loss. This observed situation was not compliant with NFPA 99 (1999 edition), 3-5.4.1.1, and NFPA 110 (1999 edition), 6-4.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

3. On 1/3/2011 at 3:00 pm surveyor #12187 observed that during a review of facility documents, there was no weekly visual inspections of the generator fluids, and no general condition of the generators were recorded. There was no weekly inspections for any of the 3 generators. This observed situation was not compliant with NFPA 110 (1999 edition), 6-3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide a Type I essential electrical system that was properly divided. This deficiency occurred in 4 of the 15 smoke compartments, and had the potential to affect all of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 1/5/2011 at 8:06 am surveyor #12187 observed that the type 1 emergency electrical system did not have the critical care outlets identified in the 1975 building. In addition, in the critical care areas, it could not be determined if the critical care outlets were on two different transfer switches. This observed situation was not compliant with NFPA 99 (1999 edition) 3-4.2.2.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

Based on observation and interview, the facility did not provide and maintain a safe electrical system. This deficiency occurred in 2 of the 15 smoke compartments, and had the potential to affect 10 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 1/5/2011 at 9:35 am surveyor #12187 observed in the #13 smoke compartment on the basement floor in the Purchasing storage room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a microwave oven and a toaster. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).

2. On 1/4/2011 at 9:55 am surveyor #12187 observed in the #7 smoke compartment on the 3rd floor in the Nurse station for geriatric unit, that a flexible cord was used in a manner that is not permitted by the code. The cord passed underneath a door opening on the floor. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff H (Director of Plant Operation).