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Based on observation of the physical environment and interview with the facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors able to resist the passage of smoke as required, thereby creating a hazardous condition.

The findings include:

Throughout the initial survey between 0940 and 1030 hours on January 29, 2013 at approximately 1330 hours on January 31, 2013 it was observed and confirmed through interview with the Supervisor of Facilities, Supervisor of Construction, and the Safety Officer that the corridor doors to resident rooms on wing "2 Central" are two leaf doors. These doors are equipped with a flush bolt latch on one leaf that engages a striker on the overhead door frame and a second leaf with a passage type door knob latch. These doors are required to have the small leaf closed and latched when not in use. The doors in these wings when both leaves are closed have a greater than 1/8" gap between the door leaves, therefore rendering the doors non-smoke resistive. A random sampling of the gaps observed were measured as stated below between the leaves of the doors in this area. These doors are required to be smoke resistive and as such the two leaf doors are to be equipped with an astragal, rabbet, or bevel as required to eliminate the gap between the door leaves. A sampling of 10 of 30 patient room doors revealed :

Room 27- 7/16" gap between doors
Room 26- 7/16" gap between doors
Room 25- 7/16" gap between doors
Room 23- 3/8" gap between doors
Room 21- 1/2" gap between doors
Room 20- 3/8" gap between doors
Room 9- 7/16" gap between doors
Room 5- 3/8" gap between doors
Room 2- 3/8" gap between doors
Room 1- 1/2" gap between doors

These conditions could prevent the proper closing of the doors to resist the passage of smoke in the event of a fire and has the potential to promote harm to occupants of the facility.

(See also CMS Memo S&C-07-18 dated 4/10/2007)

Based on observation of the physical environment and interviews with the facility staff it was determined that the facility staff failed to provide as safe an environment as possible not having all stairways properly identified thereby creating an unsafe condition.

The findings include:

Throughout the initial survey on January 29 and 31, 2013 it was observed and confirmed through an interview with the Supervisor of Facilities and the Supervisor of Construction that the Exit Stairways spanning five or more stories within the facility do not display proper stair identification signs as required at all levels to comply with this Code. The facility shall perform an audit of all stairways required to be identified by this Code to insure full compliance. (101-7.2.2.5.4)

Failure to maintain the exits, stairways, and exit passageways as required by the Code has the potential to promote harm to occupants of the facility in the event of a fire.

Based observation of the physical environment, review of the facility's records, and interview with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining all water based suppression systems as required by NFPA 25.

The findings include:

1) During the initial survey on January 29, 2013 between 0900 hours and 1100 hours it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Supervisor of Facilities and the Supervisor of Construction that the standpipe system for the facility is not documented as having been inspected, tested and maintained in accordance with NFPA 25 within the past year as required.

2) During the initial survey on January 29, 2013 between 0900 hours and 1100 hours it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Supervisor of Facilities and the Supervisor of Construction that the required five year private hydrant and private water main system test has not been performed and is overdue. No reports for a previous 5 year flow/obstruction test were made available during this survey.

Reports showing completion of the required inspections, tests, maintenance, and any required service (repairs) related to these systems shall be forwarded to this surveyor. These suppression system components shall be included in the facility's ongoing testing and maintenance programs/contracts.

The failure to maintain the water based suppression systems as required could lead to improper operation of the systems in the event of an emergency thereby promoting harm to occupants of the facility.

Based on observation of the physical environment and interview with the facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors able to resist the passage of smoke as required, thereby creating a hazardous condition.

The findings include:

Throughout the initial survey between 0940 and 1030 hours on January 29, 2013 at approximately 1330 hours on January 31, 2013 it was observed and confirmed through interview with the Supervisor of Facilities, Supervisor of Construction, and the Safety Officer that the corridor doors to resident rooms on wing "2 Central" are two leaf doors. These doors are equipped with a flush bolt latch on one leaf that engages a striker on the overhead door frame and a second leaf with a passage type door knob latch. These doors are required to have the small leaf closed and latched when not in use. The doors in these wings when both leaves are closed have a greater than 1/8" gap between the door leaves, therefore rendering the doors non-smoke resistive. A random sampling of the gaps observed were measured as stated below between the leaves of the doors in this area. These doors are required to be smoke resistive and as such the two leaf doors are to be equipped with an astragal, rabbet, or bevel as required to eliminate the gap between the door leaves. A sampling of 10 of 30 patient room doors revealed :

Room 27- 7/16" gap between doors
Room 26- 7/16" gap between doors
Room 25- 7/16" gap between doors
Room 23- 3/8" gap between doors
Room 21- 1/2" gap between doors
Room 20- 3/8" gap between doors
Room 9- 7/16" gap between doors
Room 5- 3/8" gap between doors
Room 2- 3/8" gap between doors
Room 1- 1/2" gap between doors

These conditions could prevent the proper closing of the doors to resist the passage of smoke in the event of a fire and has the potential to promote harm to occupants of the facility.

(See also CMS Memo S&C-07-18 dated 4/10/2007)

Based on observation of the physical environment and interviews with the facility staff it was determined that the facility staff failed to provide as safe an environment as possible not having all stairways properly identified thereby creating an unsafe condition.

The findings include:

Throughout the initial survey on January 29 and 31, 2013 it was observed and confirmed through an interview with the Supervisor of Facilities and the Supervisor of Construction that the Exit Stairways spanning five or more stories within the facility do not display proper stair identification signs as required at all levels to comply with this Code. The facility shall perform an audit of all stairways required to be identified by this Code to insure full compliance. (101-7.2.2.5.4)

Failure to maintain the exits, stairways, and exit passageways as required by the Code has the potential to promote harm to occupants of the facility in the event of a fire.

Based observation of the physical environment, review of the facility's records, and interview with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining all water based suppression systems as required by NFPA 25.

The findings include:

1) During the initial survey on January 29, 2013 between 0900 hours and 1100 hours it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Supervisor of Facilities and the Supervisor of Construction that the standpipe system for the facility is not documented as having been inspected, tested and maintained in accordance with NFPA 25 within the past year as required.

2) During the initial survey on January 29, 2013 between 0900 hours and 1100 hours it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Supervisor of Facilities and the Supervisor of Construction that the required five year private hydrant and private water main system test has not been performed and is overdue. No reports for a previous 5 year flow/obstruction test were made available during this survey.

Reports showing completion of the required inspections, tests, maintenance, and any required service (repairs) related to these systems shall be forwarded to this surveyor. These suppression system components shall be included in the facility's ongoing testing and maintenance programs/contracts.

The failure to maintain the water based suppression systems as required could lead to improper operation of the systems in the event of an emergency thereby promoting harm to occupants of the facility.