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Based on observation and interview the facility failed to provide corridor doors that resisted the passage of smoke and have no impediment to the closing of such doors in accordance to NFPA 101 ( 2000 edition) Section 19.3.6.3.1, this requirement was not in compliance as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: Observation revealed at 12:43 pm on Tuesday, September 3rd, 2013, that the west door into the corridor system from the Kitchen was not equipped with a positive latching mechanism.

Item 2: Observation revealed at 2:15 pm on Tuesday, September 3rd, 2013, that a brush astragal at the meeting edge of the double doors into the ED Suite prevented the north leaf from latching into the frame.

These deficient practices were confirmed by Staff BB (Maintenance Manager) at the time of discovery.

Based on observation and interviews the facility failed to provide one-hour rated walls and 45-minute rated doors into hazardous areas per NFPA 101 - 2000 edition, Section 19.3.2. as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: Observation revealed at 12:57 pm on Tuesday September 3rd, 2013, that the east wall of the Dietary office was not sealed with gypsum wallboard and taped and plastered to a one-hour fire barrier standard. This wall is a common wall with a storage room which is enclosed with a one-hour fire rated walls.

Item 2: Observation revealed at 1:03 pm on Tuesday September 3rd, 2013, that the west wall of the Acute Storage room (across the corridor from #1508) had a fire sprinkler line that penetrated that wall and was not fire caulked to a one-hour fire barrier standard.

Item 3: Observation revealed at 2:24 pm on Tuesday September 3rd, 2013, that the west wall of the Ambulance garage had a fire sprinkler pipe penetration in that wall which was not fire caulked to a one-hour fire barrier standard.

These deficient practices were confirmed by Staff BB (Maintenance Manager) at the time of discovery.

Based on observation and interviews the facility failed to provide a sprinkler system that complied with the minimum requirements of NFPA 13 (1999 edition) and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: Observation revealed at 12:43 pm on September 3rd, 2013, that the sidewall sprinkler head within Chemical Storage for Dietary was recessed into the wall, only a small portion of the tip of this head was in front of the wall face. The opening at the sprinkler head was also not sealed with an escutcheon.

Item 2: Observation revealed at 1:29 pm on September 3rd, 2013, that the pendant sprinkler head within the Toilet for Room #1508 had only a small portion exposed to the room. The opening at the sprinkler head was also not sealed with an escutcheon.

These deficient practices were confirmed by Staff BB (Maintenance Manager) at the time of discovery.

Based on observation and interviews the facility failed to provide electrical wiring and equipment in accordance to NFPA 70 Article 110, and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: Observation revealed at 2:19 pm on September 3rd, 2013, the main electrical distribution room for the ED suite was protected with a sprinkler system. However, the electrical gear was not protected from the discharge of a sprinkler head with non-combustible shields.

Item 2: Observation revealed at 2:46 pm on September 3rd, 2013, the main electrical distribution room for normal power (across the hall from Materials management) was protected with a sprinkler system. However, the electrical gear was not protected from the discharge of a sprinkler head with non-combustible shields.

Item 3: Observation revealed at 2:48 pm on September 3rd, 2013, the main electrical distribution room for emergency power (across the hall from Materials management) was protected with a sprinkler system. However, the electrical gear was not protected from the discharge of a sprinkler head with non-combustible shields.

These deficient practices were confirmed by Staff BB (Maintenance Manager) at the time of discovery.

Based on observation and interview the facility failed to provide corridor doors that resisted the passage of smoke and have no impediment to the closing of such doors in accordance to NFPA 101 ( 2000 edition) Section 19.3.6.3.1, this requirement was not in compliance as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: Observation revealed at 12:43 pm on Tuesday, September 3rd, 2013, that the west door into the corridor system from the Kitchen was not equipped with a positive latching mechanism.

Item 2: Observation revealed at 2:15 pm on Tuesday, September 3rd, 2013, that a brush astragal at the meeting edge of the double doors into the ED Suite prevented the north leaf from latching into the frame.

These deficient practices were confirmed by Staff BB (Maintenance Manager) at the time of discovery.

Based on observation and interviews the facility failed to provide one-hour rated walls and 45-minute rated doors into hazardous areas per NFPA 101 - 2000 edition, Section 19.3.2. as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: Observation revealed at 12:57 pm on Tuesday September 3rd, 2013, that the east wall of the Dietary office was not sealed with gypsum wallboard and taped and plastered to a one-hour fire barrier standard. This wall is a common wall with a storage room which is enclosed with a one-hour fire rated walls.

Item 2: Observation revealed at 1:03 pm on Tuesday September 3rd, 2013, that the west wall of the Acute Storage room (across the corridor from #1508) had a fire sprinkler line that penetrated that wall and was not fire caulked to a one-hour fire barrier standard.

Item 3: Observation revealed at 2:24 pm on Tuesday September 3rd, 2013, that the west wall of the Ambulance garage had a fire sprinkler pipe penetration in that wall which was not fire caulked to a one-hour fire barrier standard.

These deficient practices were confirmed by Staff BB (Maintenance Manager) at the time of discovery.

Based on observation and interviews the facility failed to provide a sprinkler system that complied with the minimum requirements of NFPA 13 (1999 edition) and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: Observation revealed at 12:43 pm on September 3rd, 2013, that the sidewall sprinkler head within Chemical Storage for Dietary was recessed into the wall, only a small portion of the tip of this head was in front of the wall face. The opening at the sprinkler head was also not sealed with an escutcheon.

Item 2: Observation revealed at 1:29 pm on September 3rd, 2013, that the pendant sprinkler head within the Toilet for Room #1508 had only a small portion exposed to the room. The opening at the sprinkler head was also not sealed with an escutcheon.

These deficient practices were confirmed by Staff BB (Maintenance Manager) at the time of discovery.

Based on observation and interviews the facility failed to provide electrical wiring and equipment in accordance to NFPA 70 Article 110, and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:

Item 1: Observation revealed at 2:19 pm on September 3rd, 2013, the main electrical distribution room for the ED suite was protected with a sprinkler system. However, the electrical gear was not protected from the discharge of a sprinkler head with non-combustible shields.

Item 2: Observation revealed at 2:46 pm on September 3rd, 2013, the main electrical distribution room for normal power (across the hall from Materials management) was protected with a sprinkler system. However, the electrical gear was not protected from the discharge of a sprinkler head with non-combustible shields.

Item 3: Observation revealed at 2:48 pm on September 3rd, 2013, the main electrical distribution room for emergency power (across the hall from Materials management) was protected with a sprinkler system. However, the electrical gear was not protected from the discharge of a sprinkler head with non-combustible shields.

These deficient practices were confirmed by Staff BB (Maintenance Manager) at the time of discovery.