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Based on observation the facility medical gas room was not properly separated in accordance with NFPA LSC (00) Section 19.3.5.4. This deficient practice could affect all residents, visitors and staff.


Finds include:

During the facility tour on 9-15-10, at 10:00 AM, it was observed, the fire rated wall between the exit corridor and the medical gas room, had penetrations, that have not been repaired with approved materials equal to the rating of the wall. This room is located on the first floor.

This deficient practice was confirmed by the Director of Environmental Services (JM) at the time of exit interview.

Based on observation, the facility's fire alarm system is not installed in conformance with NFPA 72. This deficient practice could affect all occupants including all patients, staff and visitors.

Findings include:

During the facility tour between on 9-15-10 between 10:30 AM and 1:00 PM it was observed that several fire alarm connected smoke detectors are located within 3 feet of HVAC deflectors. They include rooms, 111,112,113,114,115,116, conference room "D", and first detector in the link to apartments. It was further observed that the 4 smoke detectors in the link to the Scofield apartments are not connected to the hospital fire alarm system. They are connected to the apartment fire alarm. The complete automatic fire alarm system is past due on annual inspection, testing & matenance as required by NFPA 72. The last documented inspection was 10-11-07.


This deficient practice was confirmed by the Director of Environmental Services (JM) at the time of exit.

Based on observation, and interview with the Director of Environmental Services, the elevator equipment room and the elevator pit in the basement was not protected with automatic fire sprinklers. This deficient practice could affect all residents, staff and visitors.

Findings include:

During the facility tour on 9-15-10 at 11:00 AM it was observed that the elevator equipment room and the elevator pit was not protected with automatic fire sprinkler heads. It was further observed that the eight (8) sprinkler heads in the connecting link to the Scofield apartments are connected to the apartment automatic sprinkler system and not the hospital system. All areas of a building shall be protected with sprinkler heads in accordance with LSC(00) Section 19.1.6 and 19.3.5.

This deficient practice was confirmed with the Director of Environmental Services (JM) at the time of discovery and at the exit interview with the Administrator.

Based on interview, the facility does not have an appropriate written policy addressing actions to be taken by staff in the event the sprinkler system is out of service. This deficient practice could affect all residents, staff and visitors.

Findings include:

Upon completion of the facility tour on 0-15-10 at 12:30 PM, based on interview with the Director of Environmental Services , it was discovered that the facility does not have a written policy on file addressing the actions required by staff in the event the required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, as required by LSC(00) section 9.7.6.1.

This deficient practice was confirmed by the Director of Environmental Services at the time of exit.

Based on interview, the facility does not have an appropriate written policy to deal with periods of time that the fire alarm may be out of service. This deficient practice could affect all residents, staff and visitors.

Finding include:

Upon conclusion of the facility tour on 9-15-10 at approximately 12:30 PM , based on interview with the Director of Environmental Services , the facility does not have an appropriate written policy on file that would outline the actions required to be carried out in the event of a fire alarm outage lasting more than 4 hours in a 24-hour period, as required by LSC(00, Section 9.7.6.1.

This deficient practice was confirmed by the Director of Environmental Services (JM) at the time of exit.

Based on observation the facility medical gas room was not properly separated in accordance with NFPA LSC (00) Section 19.3.5.4. This deficient practice could affect all residents, visitors and staff.


Finds include:

During the facility tour on 9-15-10, at 10:00 AM, it was observed, the fire rated wall between the exit corridor and the medical gas room, had penetrations, that have not been repaired with approved materials equal to the rating of the wall. This room is located on the first floor.

This deficient practice was confirmed by the Director of Environmental Services (JM) at the time of exit interview.

Based on observation, the facility's fire alarm system is not installed in conformance with NFPA 72. This deficient practice could affect all occupants including all patients, staff and visitors.

Findings include:

During the facility tour between on 9-15-10 between 10:30 AM and 1:00 PM it was observed that several fire alarm connected smoke detectors are located within 3 feet of HVAC deflectors. They include rooms, 111,112,113,114,115,116, conference room "D", and first detector in the link to apartments. It was further observed that the 4 smoke detectors in the link to the Scofield apartments are not connected to the hospital fire alarm system. They are connected to the apartment fire alarm. The complete automatic fire alarm system is past due on annual inspection, testing & matenance as required by NFPA 72. The last documented inspection was 10-11-07.


This deficient practice was confirmed by the Director of Environmental Services (JM) at the time of exit.

Based on observation, and interview with the Director of Environmental Services, the elevator equipment room and the elevator pit in the basement was not protected with automatic fire sprinklers. This deficient practice could affect all residents, staff and visitors.

Findings include:

During the facility tour on 9-15-10 at 11:00 AM it was observed that the elevator equipment room and the elevator pit was not protected with automatic fire sprinkler heads. It was further observed that the eight (8) sprinkler heads in the connecting link to the Scofield apartments are connected to the apartment automatic sprinkler system and not the hospital system. All areas of a building shall be protected with sprinkler heads in accordance with LSC(00) Section 19.1.6 and 19.3.5.

This deficient practice was confirmed with the Director of Environmental Services (JM) at the time of discovery and at the exit interview with the Administrator.

Based on interview, the facility does not have an appropriate written policy addressing actions to be taken by staff in the event the sprinkler system is out of service. This deficient practice could affect all residents, staff and visitors.

Findings include:

Upon completion of the facility tour on 0-15-10 at 12:30 PM, based on interview with the Director of Environmental Services , it was discovered that the facility does not have a written policy on file addressing the actions required by staff in the event the required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, as required by LSC(00) section 9.7.6.1.

This deficient practice was confirmed by the Director of Environmental Services at the time of exit.

Based on interview, the facility does not have an appropriate written policy to deal with periods of time that the fire alarm may be out of service. This deficient practice could affect all residents, staff and visitors.

Finding include:

Upon conclusion of the facility tour on 9-15-10 at approximately 12:30 PM , based on interview with the Director of Environmental Services , the facility does not have an appropriate written policy on file that would outline the actions required to be carried out in the event of a fire alarm outage lasting more than 4 hours in a 24-hour period, as required by LSC(00, Section 9.7.6.1.

This deficient practice was confirmed by the Director of Environmental Services (JM) at the time of exit.