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Based on observation and testing, the facility failed to provide the two hour fire separation between non-conforming building.

Findings Include:

While inspecting the 2 hour between the hospital and assembly occupancy on April 25, 2012 at 2:45 p.m., the surveyor and Maintenance Director observed the following deficient items in two hour fire separation:

1) Open and unsealed penetrations in 2 hour wall on the 6th floor between the nursing training department and the assembly meeting area.
2) A 90 min fire rated door is needed on the unidentified office on the 2nd floor near the north elevator lobby.
3) A 90 min door is needed in the open doorway by the lobby on the 2nd floor.

These deficient practices have the potential of effecting the entire facility.

The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide shaft partitions that have a fire resistance rating of at least one hour.

Findings Include:

While inspecting vertical openings on April 25, 2012, the surveyor and Maintenance Supervisor observed deficient items in the following vertical shafts:

1) Elevator shafts #4 and #5 have open penetrations on all floors.

The Maintenance Supervisor and the Administrator were notified during the exit conference.

This deficient practice has the potential of effecting the entire facility.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect about 100% of the residents and staff.

Finding Include:

While inspecting smoke barrier walls on April 25, 2012, the Maintenance Supervisor and the surveyor observed that all the smoke barrier walls had unsealed and open penetrations in the following areas:

1) 6th floor
2) 5th floor
3) 4th floor
4) 3rd floor
5) Lobby floor
6) Basement

This deficient practice has the potential of affecting all 34 smoke compartments. The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This deficient practice affected one (1) of eight (8) smoke compartments.

Findings Include:

During the survey on April 25, 2012 at 2:15 p.m., the Maintenance Supervisor and the surveyor found the following rooms was being used for storage:

1) Room #601 contained hospital supplies and equipment and did not have 45 minute rated doors and automatic door closures installed .
2) Pink lady storage room on the 1st floor requires a self-closing device.
3) Mechanical Room in the Emergency Room X-ray, door did not have automatic door closures installed .
4) The penetration of an AC Unit on the one hour separation in generator Room #1.

On April 25, 2012, the Maintenance Supervisor and the Administrator were notified during the exit conference.

Based on observation, the facility failed to provide the Gift Shop to be protected as a hazardous area when used for storage or display of combustibles in quantities considered hazardous.

Findings Include:

While surveying the Gift Shop on April 25, 2012, the surveyor and Maintenance Director observed that the doors did not have automatic door closures.

This deficient practices have the potential of effecting the entire facility.

The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system. This condition affected 100% of the residents and staff as all smoke compartments were affected. NFPA 72 Section 1-5.6

Findings Include:

On April 24, 2012, the maintenance supervisor and surveyor observed that all emergency strobes lights need to be synchronized on all floors.

The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide the two hour fire separation between non-conforming building.

Findings Include:

While inspecting the 2 hour between the hospital and assembly occupancy on April 25, 2012 at 2:45 p.m., the surveyor and Maintenance Director observed the following deficient items in two hour fire separation:

1) Open and unsealed penetrations in 2 hour wall on the 6th floor between the nursing training department and the assembly meeting area.
2) A 90 min fire rated door is needed on the unidentified office on the 2nd floor near the north elevator lobby.
3) A 90 min door is needed in the open doorway by the lobby on the 2nd floor.

These deficient practices have the potential of effecting the entire facility.

The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide shaft partitions that have a fire resistance rating of at least one hour.

Findings Include:

While inspecting vertical openings on April 25, 2012, the surveyor and Maintenance Supervisor observed deficient items in the following vertical shafts:

1) Elevator shafts #4 and #5 have open penetrations on all floors.

The Maintenance Supervisor and the Administrator were notified during the exit conference.

This deficient practice has the potential of effecting the entire facility.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect about 100% of the residents and staff.

Finding Include:

While inspecting smoke barrier walls on April 25, 2012, the Maintenance Supervisor and the surveyor observed that all the smoke barrier walls had unsealed and open penetrations in the following areas:

1) 6th floor
2) 5th floor
3) 4th floor
4) 3rd floor
5) Lobby floor
6) Basement

This deficient practice has the potential of affecting all 34 smoke compartments. The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This deficient practice affected one (1) of eight (8) smoke compartments.

Findings Include:

During the survey on April 25, 2012 at 2:15 p.m., the Maintenance Supervisor and the surveyor found the following rooms was being used for storage:

1) Room #601 contained hospital supplies and equipment and did not have 45 minute rated doors and automatic door closures installed .
2) Pink lady storage room on the 1st floor requires a self-closing device.
3) Mechanical Room in the Emergency Room X-ray, door did not have automatic door closures installed .
4) The penetration of an AC Unit on the one hour separation in generator Room #1.

On April 25, 2012, the Maintenance Supervisor and the Administrator were notified during the exit conference.

Based on observation, the facility failed to provide the Gift Shop to be protected as a hazardous area when used for storage or display of combustibles in quantities considered hazardous.

Findings Include:

While surveying the Gift Shop on April 25, 2012, the surveyor and Maintenance Director observed that the doors did not have automatic door closures.

This deficient practices have the potential of effecting the entire facility.

The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system. This condition affected 100% of the residents and staff as all smoke compartments were affected. NFPA 72 Section 1-5.6

Findings Include:

On April 24, 2012, the maintenance supervisor and surveyor observed that all emergency strobes lights need to be synchronized on all floors.

The maintenance supervisor and the administrator were notified during an exit conference.