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Based on observations, the facility has failed to properly construct and maintain a required 2-hour fire separation, in accordance with NFPA 101 (2000), Chapter 19, Sections 19.1.1.4 and 19.1.2.1. In a fire emergency, this deficient practice could adversely affect the safety of 20 of 20 patients, staff and visitors.

FINDINGS INCLUDE:

On 9/28/11 between 9:00 AM and 4:00 PM, observation revealed a non-conforming structure of wood frame construction, which was attached to the exterior wall of the hospital on the west side of the building, outside of the Maintenance Corridor exit discharge doors.

This non-conforming structure must be either;
A. Be protected with fire sprinkler protection, or
B. Be separated from the hospital with a rated 2-hour fire wall assembly.

This finding was confirmed with the Chief Building Engineer (JH) at the time of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. NFPA 101 (00), Chapter 19, Section 19.3.6.3. Roller latches are prohibited by CMS regulations in all health care facilities.

Based on observation, the facility had non-compliant corridor doors. In a fire emergency, this deficient practice could adversely affect 20 of 20 patients, staff and visitors.

FINDINGS INCLUDE:

On 9/28/11 between 9:00 AM and 4:00 PM, observation revealed the following:
A. Corridor doors to Rooms 200, 207, 211 were equipped with roller latches, instead of positive latching hardware;
B. Corridor doors to Rooms 204-4, 214, 215, 216 were not equipped with positive latching hardware;
C. The corridor door to the Nursing Dry Goods Storage Room was impeded from closing/latching due to the placement of a supply pack hung from the top of the door.

These findings were verified with the chief building engineer [JH) at the times of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - One hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with NFPA 101 (00), Chapter 8, Section 8.4.1 and Chapter 19, Section 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted, in accordance with NFPA 101 (00), Chapter 19, Section 19.3.2.1.

Based on observation, the facility failed to maintain a hazardous area door in accordance with NFPA 101 (00), Chapter 19, Section 19.3.2.1 and 19.3.6.3.2, and Chapter 8, Section 8.2.3.2.3.2. In a fire emergency, this deficient practice could adversely affect 10 of 20 patients, staff and visitors.

FINDINGS INCLUDE:

On 9/28/11 between 9:00 AM and 4:00 PM, observation revealed that the corridor door to Soiled Utility Room 204-4 was not equipped with a self-closing device.

This finding was confirmed with the chief building engineer [JH].

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Exit access is arranged so that exits are readily accessible at all times in accordance with Chapter 19, Section 19.2 and Chapter 7, Section 7.1.

Based on observation, the facility has not provided reliable, hard surfaced pathways for one or more required means of egress, beginning at required exit discharge locations and running continuously to the public way. This arrangement was not in conformance with NFPA 101 (2000), Chapter 19, Section 19.2.1 and Chapter 7, Sections 7.1 and 7.5. In a fire or other emergency, this deficient practice could adversely affect 10 of 20 patients, staff and visitors.

FINDINGS INCLUDE:

On 9/28/11 between 9:00 AM and 4:00 PM, observation revealed that the exterior exit discharge from the link to the Assisted Living Facility consisted only of a concrete pad which terminated at the lawn. There was not a continuous hard surface path from the building to the public way.

This finding was confirmed with the chief building engineer (JH) at the time of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Illumination of means of egress, including exit discharge, is arranged so that a failure of any single lighting fixture or bulb will not leave the area in darkness, and shall be in accordance with NFPA 101 (00), Chapter 7, Section 7.8.1.4.

Based on observation, the facility had exit discharge locations which were not illuminated in accordance with NFPA 101 (2000), Chapter 19, Section 19.2.8. and Chapter 7, Section 7.8. In an emergency evacuation situation, this deficient practice could adversely affect 20 of 20 patients, staff and visitors.

FINDINGS INCLUDE:

On 9/28/11 between 9:00 AM and 4:00 PM, observation revealed illumination of the means of egress at the exit discharge locations in the following areas were not properly equipped with either a two-bulb type fixture, or two light fixtures of the single-bulb type:
A. Center Wing, northwest corridor exit discharge;
B. Center Wing, southwest corridor exit discharge;
C. Physical Therapy exit discharge.

This finding was verified with the Chief Building Engineer (JH).

Based upon a review of available reports and records, it was determined the facility had failed to conduct one or more fire drills on a quarterly basis for each shift, in accordance with NFPA 101 (2000) Chapter 19, Section 19.7.1.2.. In a fire emergency, this deficient practice could adversely affect the safety of 20 of 20 patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 9/28/11 between 9:00 AM and 4:00 PM, a review of the facility's fire drill reports was conducted with the Chief Building Engineer [JH]. During the review, it was noted that the facility operates two 12-hour shifts in each 24-hour period. A review of available documentation confirmed that required fire drills were not conducted on the Night-shift [19:00 hours to 07:00 hours] during the previous 2nd and 3rd Quarters, as calculated commencing with September, 2010, forward through August, 2011.

This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.7.1.2.

Based on observations, the facility has failed to properly construct and maintain a required 2-hour fire separation, in accordance with NFPA 101 (2000), Chapter 19, Sections 19.1.1.4 and 19.1.2.1. In a fire emergency, this deficient practice could adversely affect the safety of 20 of 20 patients, staff and visitors.

FINDINGS INCLUDE:

On 9/28/11 between 9:00 AM and 4:00 PM, observation revealed a non-conforming structure of wood frame construction, which was attached to the exterior wall of the hospital on the west side of the building, outside of the Maintenance Corridor exit discharge doors.

This non-conforming structure must be either;
A. Be protected with fire sprinkler protection, or
B. Be separated from the hospital with a rated 2-hour fire wall assembly.

This finding was confirmed with the Chief Building Engineer (JH) at the time of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. NFPA 101 (00), Chapter 19, Section 19.3.6.3. Roller latches are prohibited by CMS regulations in all health care facilities.

Based on observation, the facility had non-compliant corridor doors. In a fire emergency, this deficient practice could adversely affect 20 of 20 patients, staff and visitors.

FINDINGS INCLUDE:

On 9/28/11 between 9:00 AM and 4:00 PM, observation revealed the following:
A. Corridor doors to Rooms 200, 207, 211 were equipped with roller latches, instead of positive latching hardware;
B. Corridor doors to Rooms 204-4, 214, 215, 216 were not equipped with positive latching hardware;
C. The corridor door to the Nursing Dry Goods Storage Room was impeded from closing/latching due to the placement of a supply pack hung from the top of the door.

These findings were verified with the chief building engineer [JH) at the times of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - One hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with NFPA 101 (00), Chapter 8, Section 8.4.1 and Chapter 19, Section 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted, in accordance with NFPA 101 (00), Chapter 19, Section 19.3.2.1.

Based on observation, the facility failed to maintain a hazardous area door in accordance with NFPA 101 (00), Chapter 19, Section 19.3.2.1 and 19.3.6.3.2, and Chapter 8, Section 8.2.3.2.3.2. In a fire emergency, this deficient practice could adversely affect 10 of 20 patients, staff and visitors.

FINDINGS INCLUDE:

On 9/28/11 between 9:00 AM and 4:00 PM, observation revealed that the corridor door to Soiled Utility Room 204-4 was not equipped with a self-closing device.

This finding was confirmed with the chief building engineer [JH].

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Exit access is arranged so that exits are readily accessible at all times in accordance with Chapter 19, Section 19.2 and Chapter 7, Section 7.1.

Based on observation, the facility has not provided reliable, hard surfaced pathways for one or more required means of egress, beginning at required exit discharge locations and running continuously to the public way. This arrangement was not in conformance with NFPA 101 (2000), Chapter 19, Section 19.2.1 and Chapter 7, Sections 7.1 and 7.5. In a fire or other emergency, this deficient practice could adversely affect 10 of 20 patients, staff and visitors.

FINDINGS INCLUDE:

On 9/28/11 between 9:00 AM and 4:00 PM, observation revealed that the exterior exit discharge from the link to the Assisted Living Facility consisted only of a concrete pad which terminated at the lawn. There was not a continuous hard surface path from the building to the public way.

This finding was confirmed with the chief building engineer (JH) at the time of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Illumination of means of egress, including exit discharge, is arranged so that a failure of any single lighting fixture or bulb will not leave the area in darkness, and shall be in accordance with NFPA 101 (00), Chapter 7, Section 7.8.1.4.

Based on observation, the facility had exit discharge locations which were not illuminated in accordance with NFPA 101 (2000), Chapter 19, Section 19.2.8. and Chapter 7, Section 7.8. In an emergency evacuation situation, this deficient practice could adversely affect 20 of 20 patients, staff and visitors.

FINDINGS INCLUDE:

On 9/28/11 between 9:00 AM and 4:00 PM, observation revealed illumination of the means of egress at the exit discharge locations in the following areas were not properly equipped with either a two-bulb type fixture, or two light fixtures of the single-bulb type:
A. Center Wing, northwest corridor exit discharge;
B. Center Wing, southwest corridor exit discharge;
C. Physical Therapy exit discharge.

This finding was verified with the Chief Building Engineer (JH).

Based upon a review of available reports and records, it was determined the facility had failed to conduct one or more fire drills on a quarterly basis for each shift, in accordance with NFPA 101 (2000) Chapter 19, Section 19.7.1.2.. In a fire emergency, this deficient practice could adversely affect the safety of 20 of 20 patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 9/28/11 between 9:00 AM and 4:00 PM, a review of the facility's fire drill reports was conducted with the Chief Building Engineer [JH]. During the review, it was noted that the facility operates two 12-hour shifts in each 24-hour period. A review of available documentation confirmed that required fire drills were not conducted on the Night-shift [19:00 hours to 07:00 hours] during the previous 2nd and 3rd Quarters, as calculated commencing with September, 2010, forward through August, 2011.

This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.7.1.2.