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

Findings include:

While inspecting the separation wall between the main building and the 2 story addition, on March 19, 2013 at 11:00 a.m., the surveyor and maintenance director observed the two hour fire separation had numerous penetrations throughout the entire wall.

This deficient practice has 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 partitions that have a fire resistance rating of at least one hour.

Findings include:

While inspecting vertical openings on March 19, 2013 at 10:30 a.m., the surveyor and maintenance supervisor observed deficient items in the following vertical shafts:
1) Both stairwells on the second floor had penetrations around conduit and piping.
2) Elevator shaft on 2nd floor had penetrations around conduit.
3) Elevator shaft in the basement area had several penetrations between the shaft and Equipment Room.
4) Stairwells on the first floor had penetrations on the corridor side of the shaft.

These deficient practice has the potential of effecting the entire facility. The maintenance supervisor and the administrator were notified during an exit conference.

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.

Findings include:

While inspecting smoke barrier walls on March 19, 2013 at 1:30 p.m., the maintenance supervisor could not provide any life safety documentation on where smoke barrier walls were located in the facility. The walls that were believed to be smoke barriers had numerous penetrations throughout the entire facility.

This deficient practice has the potential of effecting the entire facility. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observations the facility failed to provide doors with self-closing or automatic -closing in accordance with 19.2.2.2.6.. This condition has the potential to affect about 50% of the residents and staff.

Findings include:

While inspecting smoke barrier walls on March 19, 2013 at 1:30 p.m., the maintenance supervisor and the surveyor observed the smoke barrier door in the main corridor did not close properly to resist the passage of smoke.

This deficient practice has the potential of affecting the entire facility. 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 condition affected 25% of the residents and staff or 1 of 4 smoke compartments.

Findings include:

While inspecting hazardous areas on March 19. 2013 at 11:45 a.m., the maintenance person and the the surveyor found the following hazardous areas to have deficiencies:
1. Soiled Linen Room on the second floor did not have a self closing device installed and should be 1-hour rated.
2. Central Storage located in the basement did not have walls constructed that could resist the passage of smoke.
3. Radiology Storage Room did not have self closing device installed on door.
4. Oxygen Storage Room did not have a self closing device installed on door.
5. Generator Room located in the basement had unsealed penetrations in the walls.
6. Storage Room located behind the lab could not resist the passage of smoke because of numerous penetrations and did not have doors with frames that could resist the passage of smoke. Also self closing devices are needed on all 3 doors.
7. Medical Storage Room located on the second floor should be 1-hour rated.

This deficient practice has the potential of affecting the entire facility. 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 exit components (such as stairways) that are enclosed with construction having a fire resistance rating of at least one hour, that are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1

Findings include:

While inspecting the exit components on March 19, 2013 at 11:30 a.m., the surveyor and maintenance director observed two stairways that exited into the corridor on the first floor. The exit passage way did not provide a one hour protection to the exit. The corridor walls had numerous penetrations throughout the length of the passage way.

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 observations the facility failed to provide the required readily accessible exit access in an existing facility.

Finding include:

While inspecting the means of egress on March 19, 2013 at 1:35 p.m., the surveyor observed the magnetic lock on the Behavioral Unit door did not release when the fire alarm was activated.

This deficient practice has the potential of affecting 1 of 5 required exits. The administrator as well as the maintenance director was notified during the survey as well as the exit conference.

Based on observations, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building.

Findings Include:

While inspecting the sprinkler system on March 19, 2013 at 12:45 p.m., the surveyor and maintenance supervisor found the following areas lacking a sprinkler head installed:
1. The closet located in the first set of offices on the right lacked a sprinkler head.
2. The closet located in the office lacked a sprinkler head.
3. The nurses station lacked 2 sprinkler heads.
4. The restroom located in the clinic area lacked a sprinkler head.

This deficient practice has the potential of affecting 3 smoke compartments. The administrator as well as the maintenance director was notified during the survey as well as the exit conference.

Based on observation and testing, the facility failed to provide interior walls and partitions in buildings of Type I or type II constructing shall be noncombustible or limited-combustible materials. 18.1.6.3, 19.1.6.3.

Findings include:

While inspecting interior walls on March 19, 2013 at 12:00 p.m., the surveyor and maintenance director observed the office separation wall for an office, located inside the behavioral wing of the facility, was constructed of combustible wood.

This deficient practice has the potential of effecting the entire facility. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observations the facility failed to provide the required monthly generator testing in accordance with NFPA 99. This condition has the potential to affect 100% of the residents and staff.

Findings include:

While reviewing generator testing documentation on March 19, 2013 at 2:00 p.m., the facility failed to perform the monthly load test on the generator properly. Based on record review the load test was being performed for a duration of 15 minutes instead of the required 30 minutes.

This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey as well as the exit conference.

Based on observation and record review, the facility failed to properly install electrical wiring and equipment in accordance with NFPA 70, National Electrical Code 9.1.2

Findings include:

While inspecting electrical wiring on March 19, 2013 at 11:20 a.m., the surveyor and maintenance supervisor notice numerous junction boxes that lacked a cover. Several junction boxes throughout the facility had wiring extending about 3 feet out of the box that was exposed and hanging above the ceiling.

This deficient practice has the potential of affecting the entire facility. The administrator as well as the maintenance director was notified during the survey as well as the exit conference.

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

Findings include:

While inspecting the separation wall between the main building and the 2 story addition, on March 19, 2013 at 11:00 a.m., the surveyor and maintenance director observed the two hour fire separation had numerous penetrations throughout the entire wall.

This deficient practice has 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 partitions that have a fire resistance rating of at least one hour.

Findings include:

While inspecting vertical openings on March 19, 2013 at 10:30 a.m., the surveyor and maintenance supervisor observed deficient items in the following vertical shafts:
1) Both stairwells on the second floor had penetrations around conduit and piping.
2) Elevator shaft on 2nd floor had penetrations around conduit.
3) Elevator shaft in the basement area had several penetrations between the shaft and Equipment Room.
4) Stairwells on the first floor had penetrations on the corridor side of the shaft.

These deficient practice has the potential of effecting the entire facility. The maintenance supervisor and the administrator were notified during an exit conference.

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.

Findings include:

While inspecting smoke barrier walls on March 19, 2013 at 1:30 p.m., the maintenance supervisor could not provide any life safety documentation on where smoke barrier walls were located in the facility. The walls that were believed to be smoke barriers had numerous penetrations throughout the entire facility.

This deficient practice has the potential of effecting the entire facility. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observations the facility failed to provide doors with self-closing or automatic -closing in accordance with 19.2.2.2.6.. This condition has the potential to affect about 50% of the residents and staff.

Findings include:

While inspecting smoke barrier walls on March 19, 2013 at 1:30 p.m., the maintenance supervisor and the surveyor observed the smoke barrier door in the main corridor did not close properly to resist the passage of smoke.

This deficient practice has the potential of affecting the entire facility. 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 condition affected 25% of the residents and staff or 1 of 4 smoke compartments.

Findings include:

While inspecting hazardous areas on March 19. 2013 at 11:45 a.m., the maintenance person and the the surveyor found the following hazardous areas to have deficiencies:
1. Soiled Linen Room on the second floor did not have a self closing device installed and should be 1-hour rated.
2. Central Storage located in the basement did not have walls constructed that could resist the passage of smoke.
3. Radiology Storage Room did not have self closing device installed on door.
4. Oxygen Storage Room did not have a self closing device installed on door.
5. Generator Room located in the basement had unsealed penetrations in the walls.
6. Storage Room located behind the lab could not resist the passage of smoke because of numerous penetrations and did not have doors with frames that could resist the passage of smoke. Also self closing devices are needed on all 3 doors.
7. Medical Storage Room located on the second floor should be 1-hour rated.

This deficient practice has the potential of affecting the entire facility. 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 exit components (such as stairways) that are enclosed with construction having a fire resistance rating of at least one hour, that are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1

Findings include:

While inspecting the exit components on March 19, 2013 at 11:30 a.m., the surveyor and maintenance director observed two stairways that exited into the corridor on the first floor. The exit passage way did not provide a one hour protection to the exit. The corridor walls had numerous penetrations throughout the length of the passage way.

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 observations the facility failed to provide the required readily accessible exit access in an existing facility.

Finding include:

While inspecting the means of egress on March 19, 2013 at 1:35 p.m., the surveyor observed the magnetic lock on the Behavioral Unit door did not release when the fire alarm was activated.

This deficient practice has the potential of affecting 1 of 5 required exits. The administrator as well as the maintenance director was notified during the survey as well as the exit conference.

Based on observations, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building.

Findings Include:

While inspecting the sprinkler system on March 19, 2013 at 12:45 p.m., the surveyor and maintenance supervisor found the following areas lacking a sprinkler head installed:
1. The closet located in the first set of offices on the right lacked a sprinkler head.
2. The closet located in the office lacked a sprinkler head.
3. The nurses station lacked 2 sprinkler heads.
4. The restroom located in the clinic area lacked a sprinkler head.

This deficient practice has the potential of affecting 3 smoke compartments. The administrator as well as the maintenance director was notified during the survey as well as the exit conference.

Based on observation and testing, the facility failed to provide interior walls and partitions in buildings of Type I or type II constructing shall be noncombustible or limited-combustible materials. 18.1.6.3, 19.1.6.3.

Findings include:

While inspecting interior walls on March 19, 2013 at 12:00 p.m., the surveyor and maintenance director observed the office separation wall for an office, located inside the behavioral wing of the facility, was constructed of combustible wood.

This deficient practice has the potential of effecting the entire facility. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observations the facility failed to provide the required monthly generator testing in accordance with NFPA 99. This condition has the potential to affect 100% of the residents and staff.

Findings include:

While reviewing generator testing documentation on March 19, 2013 at 2:00 p.m., the facility failed to perform the monthly load test on the generator properly. Based on record review the load test was being performed for a duration of 15 minutes instead of the required 30 minutes.

This deficient practice has the potential of affecting the entire facility. The administrator and the maintenance director were notified during the survey as well as the exit conference.

Based on observation and record review, the facility failed to properly install electrical wiring and equipment in accordance with NFPA 70, National Electrical Code 9.1.2

Findings include:

While inspecting electrical wiring on March 19, 2013 at 11:20 a.m., the surveyor and maintenance supervisor notice numerous junction boxes that lacked a cover. Several junction boxes throughout the facility had wiring extending about 3 feet out of the box that was exposed and hanging above the ceiling.

This deficient practice has the potential of affecting the entire facility. The administrator as well as the maintenance director was notified during the survey as well as the exit conference.