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Based on observations made on March 29 and 30, 2010, the facility failed to maintain the two-hour resistance rating of fire barriers and their communicating openings in the building.

In accordance with Section 19.1.2.3 of NFPA 101, LSC, 2000 edition; buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than two hours as provided of additions in Section 19.1.1.4.

The findings include:

The two-hour fire barrier between the Clinic and the Laboratory was examined at 9:55 a.m. on March 30, 2010. At the cross corridor doors in the corridor, there was a penetration through the fire wall above the fire damper, located above the ceiling tile.

Based on observations made on March 29 and 30, 2010, the facility failed to maintain the fire and smoke resistance rating of wall assemblies.

The findings include:

In accordance with Section 19.1.6.1 of NFPA 101, LSC, 2000 edition; building construction type and height shall meet one of the following: 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1.

1. The bacteria room in the Laboratory was observed at 1:52 p.m. on March 29, 2010. There was one penetration (1/2 inch hole) of the ceiling which was not filled.

2. The Laboratory bath room was observed at 2:10 p.m. on March 29, 2010. A plumbing access panel was not tightly affixed to the wall exposing a hole measuring eight inches by twelve inches.

3. The Information Technology (IT) room on Heartway Boulevard was observed at 3:02 p.m. on March 29, 2010. There were two 3 inch conduits not sealed through the ceiling of that room.

Based on observations made on March 29 and 30, 2010, the facility failed to prevent the use of chocks or other similar devices from holding open a corridor door.

The findings include:

Hold-open devices that release when the corridor door is pushed or pulled shall be permitted per Section 19.3.6.3.3 of NFPA 101 LSC, (2000 edition). However, a hold-open device can not be used on doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, fire barrier or hazardous area enclosure unless they conform with Section 7.2.1.8.2 of NFPA 101 LSC, (2000 edition). Doors cannot be blocked open by furniture, door stops, chocks, wedges, or devices that necessitate manual releasing action to close the door.

1. The corridor door on Heartway Boulevard were observed at 12:40 p.m. on March 29, 2010. The corridor door to the Physician's sleep room had two penetrations through the door leaf where a newly installed lock had been installed and did not cover the previous holes drilled in the door leaf.

2. The cafeteria was observed at 2:05 p.m. on March 29, 2010. The corridor door to the cafeteria was being held open with a magnetized release which was connected to the Fire Alarm Control Panel (FACP). The door could not close upon alarm as there was an alcohol based sanitizer stand station placed directly in front of the corridor door. The door was released to see if it would push the sanitizer station out of the way, but the station base was too large and the swinging corridor door to the cafeteria failed to latch.

3. The corridor door to the Accounts Payable office was observed at 2:35 p.m. on March 29, 2010. The following deficiencies were noted:

a.) The corridor door was being held open with a chock like device which had been wedged under the door to keep it open. This type of device cannot be used as a means for holding a corridor door open.

b.) The same corridor door also had a grate placed in the lower portion of the door leaf to allow air circulation in the office. The grate measured eighteen inches by twenty four inches and allowed air to pass from the corridor into the office. The corridor door was not tight to the passage of smoke.

4. The corridor door to the Accounts Receivable office was observed at 2:40 p.m. on March 29, 2010. This door also had a grate placed in the lower portion of the door leaf to allow air circulation in the office. The grate measured eighteen inches by twenty four inches and allowed air to pass from the corridor into the office. The corridor door was not tight to the passage of smoke.

Based on observations made on March 29 and 30, 2010, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

In accordance with Section 18.3.1.1 of NFPA 101, 2000 edition; any vertical opening shall be enclosed or protected in accordance with Section 8.2.5 of the LSC. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 edition; pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. The penthouse above the nurse's station was observed at 3:40 p.m. on March 29, 2010. There were approximately six penetrations from penthouse level to the level below. All were conduits which had been cut off and were unsealed.

2. The north attic of Acute Care was observed at 9:35 a.m. on March 30, 2010. There were six penetrations through the floor of the attic which were not properly sealed. The unsealed conduits served as a wire chase for the heat exchanger controls.

Based on observations made on March 29 and 30, 2010, the facility failed to maintain the fire resistive rating of smoke barrier walls.

Findings include:

In accordance with Section 8.3 of NFPA 101, LSC, 2000 edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 18.3.7.3, 18.3.7.5, and 18.1.6.3 of NFPA 101, LSC (2000 edition).

1. The room housing the Fire Alarm Control Panel (FACP) was observed at 8:35 a.m. on March 30, 2010. There was an open penetration in the floor of this room for a network cable.

2. The smoke barrier wall between Acute Care and the front lobby was observed at 9:25 a.m. on March 30. 2010.

a) There was a five inch conduit through the smoke barrier wall directly above the ceiling tile above the set of double doors between Acute Care and the front lobby which was not properly sealed.

b) Also, at this same location, there was a single wire through the smoke barrier wall directly above the set of double doors between Acute Care and the front lobby which was not sealed.

3. The Acute Care attic was observed at 9:30 a.m. on March 30, 2010. Two heat exchangers mounted on the west wall in the attic were not sealed properly.

4. The smoke barrier wall in the Emergency Room alcove (supply storage area) was observed at 10:40 a.m. on March 30, 2010.

a) There was one penetration of the south wall where a sprinkler pipe was not sealed above the ceiling tile.

b) The alcove north west, outside corner wall board seam was not fire taped above the ceiling tile.

Based on observations made on March 29 and 30, 2010, the facility failed to maintain or establish the fire rated protection for a hazardous area.

The findings include:

In accordance with Section 8.4 of NFPA 101, LSC 2000 edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 18.3.2.1 of NFPA 101 LSC.

1. Maintenance staff was working on a tub room and preparing to make a new store room on the Acute Care wing as observed at 8:20 a.m. on March 30, 2010. This room was prepped for painting and all that remained was to lay in new flooring.

a) There were three penetrations where conduits were open in the ceiling of this room.

b) There were four penetrations in the east wall of this room above the ceiling tile which were not sealed.

c) The ceiling/wall joints in the wallboard had not been fire taped.

Based on observations made on March 29, 2010, the facility failed to maintain the continuous illumination for one exit sign.

Findings include:

In accordance with Sections 19.2.10.1 and 7.10.5.2 of NFPA 101, LSC, 2000 edition; exit signs shall be continuously illuminated. Exit signs that are internally illuminated must meet UL 924 standards and are listed for use only with all bulbs evenly and uniformly illuminating the letters.

The exit sign in the service corridor off of the kitchen was examined at 1:50 p.m. on March 29, 2010. Neither of the two required bulbs were illuminating the sign.

Based on observations and review of records made on March 29, 2010, the facility failed to provide for complete sprinkler protection of all portions or areas of the building.

The findings include:

The building is of Type V (111) combustible construction which requires that the facility be protected throughout by an automatic sprinkler system that meets NFPA 13 standards. In accordance with Section 19.3.5.1 of NFPA 101, LSC, (2000 edition); where required by Section 19.1.6 of NFPA 101, LSC, (2000 edition); health care facilities shall be protected by an approved, supervised automatic sprinkler system in accordance with Section 9.7 of NFPA 101, LSC.

The office used by the kitchen chef was observed at 1:30 p.m. on March 29, 2010. This room was previously a store room without a suspended ceiling. When it was made into an office space a drop ceiling was installed, but the sprinkler pipe serving the space was not extended to the level of the drop ceiling.

Based on observations made on March 29 and 30, the facility failed to assure that sprinklers were not coated with materials or residue and failed to maintain the sprinkler system in accordance with NFPA 25.

The findings include:

In accordance with Section 2-2.1.1 of NFPA 25, 1998 edition: Sprinklers shall be free of corrosion, foreign material, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall).

1. The kitchen hood was observed at 1:45 p.m. on March 29, 2010. Two sprinkler heads under the main hood contained a lint build up.

2. The dish room in the kitchen was observed at 1:47 p.m. on March 29, 2010. One sprinkler head in this room contained a lint build up.

3. The bacteria room in the Laboratory was observed at 1:51 p.m. on March 29, 2010. One escutcheon ring was missing from the sprinkler head in this room.

Based on observation made on March 29, 2010, the facility failed to maintain all portable fire extinguishers in accordance with NFPA 10.

Findings include:

In accordance with Section 1-6.10 1 of NFPA 10, 1998 edition (Portable Fire Extinguishers); fire extinguishers having a gross weight not exceeding 40 pounds shall be installed so that the top of the fire extinguisher is not more than 5 feet above the floor. Fire extinguishers having a gross weight greater than 40 pounds (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 feet above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 inches.

The laundry was observed at 1:20 p.m. on March 29, 2010. The 80 ABC portable fire extinguisher mounted near the door was mounted within three inches of the floor. It must be mounted so the clearance between the bottom of the fire extinguisher and the floor is not less than four inches.

Based on observations and staff interview made during the tour of the facility on March 29 and 30, 2010, the facility failed to provide documentation that the window curtains and valances in use were flame resistant in accordance with the standards of NFPA 701, 1999 edition or had been treated with a flame resistant product made for fabrics.

In accordance with Sections 18.7.5.1 and 10.3.1 of NFPA 101, LSC; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

Findings include:

The nursing supervisors office was observed at 8:30 on March 30, 2010. The red curtain over the window had not been sprayed with a flame resistant product made for fabrics. Interview with maintenance staff revealed that the curtain had not been treated and there was no documentation to show that it had been treated.

Based on observation made on March 30, 2010, the facility failed to secure surge cords to a surface.

Findings include:

In accordance with Article 110-13(a) of NFPA 70, 1999 edition; electrical equipment shall be firmly secured to the surface on which it is mounted.

The X-ray room was observed at 2:30 p.m. on March 30, 2010. The surge cord being used for the X-ray viewer machine and the phone was not mounted to the wall but dangled above the floor from a wall outlet.