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Based on observation and interview, the provider failed to maintain the fire-resistive characteristics of the two hour fire-resistive wall between the hospital and the clinic. The roof deck was not sealed, and there was a one hour fire-rated door in the two hour wall. Findings include:

1. Observation at 8:30 a.m. on 6/12/12 revealed the top of the two hour separation wall between the clinic and the hospital was not sealed at the roof deck. Fire safing insulation was placed in the decking open spaces above the 5/8 inch thick gypsum board on the wall. The safing insulation was not sealed with an approved firestop material.

2. Observation at 8:45 a.m. on 6/12/12 revealed a door located in the two hour wall between the clinic business office and the business office storeroom.

The door was a labeled one hour fire-rated door. A door in a two hour fire-rated separation wall must have at least a 90 minute fire-rating.

Doors in two hour fire-rated separation walls are only permitted in corridors (the clinic was completely sprinklered, the clinic storeroom was not sprinklered). The clinic business office and the clinic storeroom must be provided with smoke detectors interconnected to the fire alarm system.
Each of the smoke detectors must be situated within five feet of the door in the two hour wall for this unique application.

Interview with the administrator at 10:00 a.m. on 6/12/12 revealed he was unaware the two hour fire-rated wall and the clinic one hour fire-rated door did not meet the standard.

Based on observation, the provider failed to maintain at least two conforming exits from the basement. Findings include:

1. Observation on 6/11/12 revealed the basement was not provided with an approved means of egress. One exit was through a window that was equipped with a fixed ladder. The other exit discharged into the main level laundry room area (hazardous area).

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

Based on observation, the provider failed to maintain a one hour fire resistive path of egress from the basement to the exterior of the building. The basement stairway discharged into the main level corridor system. Findings include:

1. Observation on 6/11/12 revealed the basement stairway adjacent to the laundry room area discharged into the main level corridor system. A one hour fire resistive path of egress was not provided to the exterior of the building.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

Based on observation and interview, the provider failed to ensure one of three exits were paved to the public way. The north exit was not paved to the public way. Findings include:

1. Observation at 2:30 p.m. on 6/11/12 revealed the north exit was paved to the helipad but was not paved to a public way. Interview with the maintenance supervisor at the time of the observation revealed the closest paving was the northwest parking lot approximately 25 feet away.

Based on observation and interview, the provider failed to provide exit signs with continuous illumination. One of three exit signs for the west exit (the sign was in the main corridor) was not illuminated when the generator was running. Findings include:

1. Observation at 4:00 p.m. on 6/11/12 revealed the exit sign for the west exit was not lit when facility power was shut off and the generator was running. Interview with the maintenance supervisor at the time of the observation revealed the sign had been lit prior to shutting the power down to start the generator. He stated the sign must not have been interconnected to the emergency circuit.

Based on observation and interview, the provider failed to install the north exit manual pull station at the proper height. The operating part of the pull station was situated 61 inches above the finished floor. Findings include:

1. Observation at 2:45 p.m. on 6/11/12 revealed the manual pull station on the west wall at the north exit was mounted so the operating part of the station was 61 inches above the finished floor. The height for mounting a manual pull station is to have the operating part of the pull station between 42 to 54 inches above the finished floor.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

Based on document review and interview, the provider failed to adopt a complete smoking policy that dealt with staff and patient smoking. Findings include:

1. Review of the provider's policies revealed they did not prohibit smoking by residents who were classified as not responsible to smoke on their own except under direct supervision. Interview with the safety coordinator at 3:30 p.m. on 6/11/12 revealed the provider did not have a written policy to deal with smoking by staff or residents other than no smoking in the building.

Based on observation and interview, the provider failed to maintain means of egress free of impediment to full instant use in two randomly observed areas (the IT room corridor door and the east exit vestibule door) by using floor wedges to prop those doors open. Findings include:

1. Observation at 2:15 p.m. on 6/11/12 revealed the IT room in the north wing was propped open with a floor wedge. The wedge could interfere with egress through the door in an emergency by blocking the door in a partially open position.

2. Observation at 3:45 p.m. on 6/11/12 revealed the vestibule door to the east exit was held in the open position with a floor wedge. The wedge could interfere with egress through the door in an emergency by blocking the door in a partially open position.

3. Interview with the administrator at 9:30 a.m. on 6/12/12 revealed acceptable hold open devices such as friction catches could be installed on the doors.

The provider must comply with the National Fire Protection Association (NFPA 99), Standard for Health Care Facilities, section 9.4.2(A) Cylinder and Container Storage Requirements.
Based on observation and interview, the provider failed to provide an enclosure with securable gates around the outside liquid oxygen cylinder storage location. One of the spare liquid oxygen tanks was restrained but was not enclosed to prevent unauthorized tampering with the cylinder. Findings include:

1. Observation at 3:20 p.m. revealed one of the spare liquid oxygen tanks was restrained but was not enclosed to prevent unauthorized tampering with the cylinder. Interview with the maintenance supervisor at the time of the observation confirmed that condition. He stated the extra spare cylinder was needed to bridge any time delay in standard delivery schedules of cylinders should a higher volume of gas be used than normal between deliveries.

A. Based on document review and interview, the provider failed to conduct monthly exercise testing with load for a 30 minute duration plus cool down period for the emergency generator for two months during 2011 (January and February). Findings include:

1. Review of the generator log revealed the monthly emergency generator load runs revealed the generator load tests were not performed in January or February 2011. A note indicated the maintenance supervisor had been away from work due to surgery. Interview with the administrator at 9:30 a.m. on 6/12/12 revealed no one else had been assigned to conduct the monthly generator load testing during the maintenance supervisor's absence.

B. Based on testing and interview, the provider failed to maintain battery pack illumination for the emergency generator transfer switch location in the basement. Findings include:

1. Testing at 2:45 p.m. on 6/11/12 of the battery pack light fixture in the stair enclosure to the basement generator transfer switch location revealed the light did not function when tested. Interview with the maintenance supervisor at the time of the testing confirmed that finding.

C. Based on observation and interview, the provider failed to install terminal covers for the generator battery and failed to install a battery that was not maintenance-free. Findings include:

1. Observation at 9:50 a.m. on 6/11/12 revealed the generator battery did not have covers on the terminals. Interview with the maintenance supervisor at the time of the observation revealed he had tried using plastic spray can lids, but they would blow off the terminal location. He stated he would get some automotive rubber terminal covers.

2. Observation at 9:55 a.m. on 6/11/12 revealed the generator battery was a maintenance-free battery. Interview with the maintenance supervisor at the time of the observation revealed the battery had been recently installed along with a new battery charger. He was unaware that maintenance-free batteries were not acceptable for Level 1 installations.