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Based on observations made during the survey of the facility between the hours of 11:00 am and 2:30 pm, while accompanied by the Compliance Officer and the Maintenance Director the Surveyor requested information on the location of one or both of the following:
(a) 1 hour fire-rated SMOKE BARRIER WALLS which subdivide the facility into different SMOKE COMPARTMENTS.
(b) 1 hour fire-rated FIRE BARRIER WALLS which subdivide the facility into different FIRE ZONES.

No documented information was provided for the Surveyor. Therefore the Surveyor was unable to establish a thorough check as to whether the facility was maintaining the integrity of such construction as is required for LIFE SAFETY.

In conclusion, the facility needs to have information at hand regarding SMOKE COMPARTMENTS or FIRE ZONES in order to:

A. Properly train and prepare staff for potential relocation of patients to "safe" areas during the time of a fire.

B. Assist patients/staff/visitors in finding best options for "safety" during the time of a fire.

C. Assist Emergency Responders in making best determinations/decisions for staging the fire department's equipment and personell as they arrive during the time of a fire, as well as throughout the durration of their response efforts.

ADDITIONALLY:

The Surveyor discussed a "potentially" dangerous finding observed at the exterior area of the campus near the BULK OXYGEN TANK. The local electric power utility company has an electrical utility power line pole which is heaviliy loaded at the top with three (3) TRANSFORMERS, and that power pole is severly leaning in the direction of the BULK OXYGEN TANK. It was discussed that this pole with it's transformers would need to be relocated, and the very real potential for danger needs to go away quickly.

Based on observations made during the survey of the facility between the hours of 11:00 am and 2:30 pm, while accompanied by the Acting Administrator and Director of Nursing it was observed that although it appears the facility had accomplished some of the requirements, the facility failed to provide a log documenting consistent, systematic records on the facility's weekly observances of the Generator equipment system.

The WEEKLY LOG records for Generator Observation should include information on the following:

· TIME/DATE/PERSONELL

as well as records regarding checks on

· OPERATIONAL/MAINTENANCE issues such as:
o Fluid levels
o Belts_Hoses
o Battery(s)
o Fuel supply level(s)
o Leaks
o Emergency shut-off(s)
o etc.

Based on observations made during the survey of the facility between the hours of 11:00 am and 2:30 pm, while accompanied by the Compliance Officer and the Maintenance Director the Surveyor requested information on the location of one or both of the following:
(a) 1 hour fire-rated SMOKE BARRIER WALLS which subdivide the facility into different SMOKE COMPARTMENTS.
(b) 1 hour fire-rated FIRE BARRIER WALLS which subdivide the facility into different FIRE ZONES.

No documented information was provided for the Surveyor. Therefore the Surveyor was unable to establish a thorough check as to whether the facility was maintaining the integrity of such construction as is required for LIFE SAFETY.

In conclusion, the facility needs to have information at hand regarding SMOKE COMPARTMENTS or FIRE ZONES in order to:

A. Properly train and prepare staff for potential relocation of patients to "safe" areas during the time of a fire.

B. Assist patients/staff/visitors in finding best options for "safety" during the time of a fire.

C. Assist Emergency Responders in making best determinations/decisions for staging the fire department's equipment and personell as they arrive during the time of a fire, as well as throughout the durration of their response efforts.

ADDITIONALLY:

The Surveyor discussed a "potentially" dangerous finding observed at the exterior area of the campus near the BULK OXYGEN TANK. The local electric power utility company has an electrical utility power line pole which is heaviliy loaded at the top with three (3) TRANSFORMERS, and that power pole is severly leaning in the direction of the BULK OXYGEN TANK. It was discussed that this pole with it's transformers would need to be relocated, and the very real potential for danger needs to go away quickly.

Based on observations made during the survey of the facility between the hours of 11:00 am and 2:30 pm, while accompanied by the Acting Administrator and Director of Nursing it was observed that although it appears the facility had accomplished some of the requirements, the facility failed to provide a log documenting consistent, systematic records on the facility's weekly observances of the Generator equipment system.

The WEEKLY LOG records for Generator Observation should include information on the following:

· TIME/DATE/PERSONELL

as well as records regarding checks on

· OPERATIONAL/MAINTENANCE issues such as:
o Fluid levels
o Belts_Hoses
o Battery(s)
o Fuel supply level(s)
o Leaks
o Emergency shut-off(s)
o etc.