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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls and sealed wall penetrations. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 4/2/2013 at 4:18 pm, observation revealed on the 1st floor in the large activity room, that penetration(s) were not sealed according to an approved method. The deficiency included holes that were found where the ceiling had been attached to the wall and had been removed. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

2. On 4/3/2013 at 11:15 am, observation revealed on the 1st floor in the large activity room, that penetration(s) were not sealed according to an approved method. The deficiency included a hole from ducts above the door from the activity room to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff V (Director of Facilities) and staff M (CEO).
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Based on observation and interview, the facility failed to provide a door from the sleeping room to a corridor or have a door leading directly to grade. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within the smoke compartments.

FINDINGS INCLUDE:

On 4/2/2013 at 3:45 pm, observation revealed on the 1st floor in the large activity room, that Patient rooms D135, D136, D137, D138, D139 and D140 did not have doors that lead directly to an egress corridor or to grade. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff V (Director of Facilities) and staff M (CEO).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with non-sprinkled rooms that met permitted exceptions. This deficiency occurred in a smoke compartment, and had the potential to affect all inpatients, outpatients, staff and visitors within the hospital.

FINDINGS INCLUDE:

On 4/3/2013 at 11:30 am, observation revealed on the 1st floor in the generator room, that the room was not sprinkler protected, although the entire facility was required to be sprinkled to meet a construction exception. The facility did not meet all the requirements of the code to avoid sprinkling the space. For the electrical equipment rooms to be except from sprinkler requirements, the electrical room is required to meet four conditions. The generator is combustible fuel burning device and is not a dry-type electric piece of equipment. The room also contained combustible storage and hence was not dedicated to electrical equipment. This observed situation was not compliant with NFPA 13, 5-13.11(b) and (d) (1999 ed.).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff V (Director of Facilities) and staff M (CEO).
______________________________________

Based on observation and interview, the facility failed to provide proper airflow in the corridor. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within the smoke compartment.

FINDINGS INCLUDE:
On 4/2/2013 at 3:55 pm, observation revealed on the 1st floor in the large activity room, that the common space (corridor) is being used for makeup air (corridor plenum) into the individual patient rooms D135, D136, D137, D138, D139 and D140. This observed situation was not compliant with NFPA 90A (1999 ed.), section 19.2.5.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff V (Director of Facilities) and staff M (CEO).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls and sealed wall penetrations. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 4/2/2013 at 4:18 pm, observation revealed on the 1st floor in the large activity room, that penetration(s) were not sealed according to an approved method. The deficiency included holes that were found where the ceiling had been attached to the wall and had been removed. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

2. On 4/3/2013 at 11:15 am, observation revealed on the 1st floor in the large activity room, that penetration(s) were not sealed according to an approved method. The deficiency included a hole from ducts above the door from the activity room to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff V (Director of Facilities) and staff M (CEO).
______________________________________

Based on observation and interview, the facility failed to provide a door from the sleeping room to a corridor or have a door leading directly to grade. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within the smoke compartments.

FINDINGS INCLUDE:

On 4/2/2013 at 3:45 pm, observation revealed on the 1st floor in the large activity room, that Patient rooms D135, D136, D137, D138, D139 and D140 did not have doors that lead directly to an egress corridor or to grade. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.5.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff V (Director of Facilities) and staff M (CEO).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with non-sprinkled rooms that met permitted exceptions. This deficiency occurred in a smoke compartment, and had the potential to affect all inpatients, outpatients, staff and visitors within the hospital.

FINDINGS INCLUDE:

On 4/3/2013 at 11:30 am, observation revealed on the 1st floor in the generator room, that the room was not sprinkler protected, although the entire facility was required to be sprinkled to meet a construction exception. The facility did not meet all the requirements of the code to avoid sprinkling the space. For the electrical equipment rooms to be except from sprinkler requirements, the electrical room is required to meet four conditions. The generator is combustible fuel burning device and is not a dry-type electric piece of equipment. The room also contained combustible storage and hence was not dedicated to electrical equipment. This observed situation was not compliant with NFPA 13, 5-13.11(b) and (d) (1999 ed.).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff V (Director of Facilities) and staff M (CEO).
______________________________________

Based on observation and interview, the facility failed to provide proper airflow in the corridor. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within the smoke compartment.

FINDINGS INCLUDE:
On 4/2/2013 at 3:55 pm, observation revealed on the 1st floor in the large activity room, that the common space (corridor) is being used for makeup air (corridor plenum) into the individual patient rooms D135, D136, D137, D138, D139 and D140. This observed situation was not compliant with NFPA 90A (1999 ed.), section 19.2.5.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff V (Director of Facilities) and staff M (CEO).