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Based on observation and interview, the facility did not enclose hazardous rooms that had rated doors. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 5 of the 35 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 3/31/2011 at 12:30 pm surveyor #22219, #13960, and #22994 observed in the #1 smoke compartment on the 3rd floor in the Pharmacy Room, that the door to the room did not have any label to confirm it had at least a 45 minute rating. 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 A (Director of Plant Operation), staff B (Environmental Services Manager), staff C (President), and staff D (Lead Maintenence Worker).

This observation was also made during the original recertification survey on January 5, 2011. Several improvements had been made to the room to satisfy the originally cited deficiency and the replacement door was on order. The facility indicated that the original Plan of Correction date of 2/21/2011 for correction was a typographical error that should have read 5/21/2011.

Based on observation and interview, the facility did not provide egress paths with sufficient headroom. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 3/31/2011 at 11:45 am surveyor #22219, #13960, and #22994 observed in the #13 smoke compartment on the basement floor in the Bryant Center, that the headroom was 6 feet 6 inches through four exit doors. The low doors were located in four moveable partitions that create separate staff meeting rooms in the Bryant Dining Center. 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 A (Director of Plant Operation), staff B (Environmental Services Manager), staff C (President), and staff D (Lead Maintenence Worker).

This observation was also made during the original recertification survey on January 5, 2011. The facility's Plan of Correction had indicated that the doors would be replaced by April 18, 2011.

Based on observation and interview, the facility failed to provide stairwells that were protected from hazards identified in the code.

FINDINGS INCLUDE:
On 3/31/2011 at 11:30 am surveyor #22219, #13960, and #22994 observed in smoke compartment #9 on the lower level by the exit stair in the 1956 building that the LL326 belt room was an unoccupied room which opened into the stairwell enclosure. The room contained a supply of V-Belts, metal maintenance parts, and two 400A electrical disconnects. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Plant Operation), staff B (Environmental Services Manager), staff C (President), and staff D (Lead Maintenence Worker).

This observation was also made during the original recertification survey on January 5, 2011. The facility's Plan of Correction was to request a hardship waiver. Sufficient information was not received at the time of the verification visit to support a waiver request.

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 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:
On 3/31/2011 at 1:00 pm surveyor #22219, #13960, and #22994 learned, via interview with staff A (Director of Plant Operation), staff B (Environmental Services Manager), and staff C (President), that the exterior path of egress of the second exit from the Stoughton Clinic was over a grass path from the side of the building to the front. The exit discharge path was only an 8 by 8 foot stoop on the outside of the exterior exit door through the horizontal exit wall. An alternative door through the 2-hour rated horizontal exit wall was not signed as an exit and was locked with a barrel bolt.

This observation was also made during the original recertification survey on January 5, 2011. The facility's Plan of Correction was to request a hardship waiver. Sufficient information was not received at the time of the verification visit to support a waiver request.