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Through observation, during the survey, April 11, 2013, it was determined that the facility failed to maintain the two hour fire resistance rating of the common wall between the Hospital and other occupancies.

During the walk through of the facility, with the Maintenance Director, the fire barrier walls contained unsealed wire penetrations in the following areas:
1) The two-hour (2) wall at the main conference room contained two (2) unsealed wire penetrations.
2) The two-hour (2) wall at the main conference room contained one (1) two inch by two inch (2"x2") piece of missing drywall
3) The two-hour (2) wall at the rehabilitation clinic contained drywall that went up to the corrugated metal deck. The space between the corrugated deck and the drywall did not contain a fire rated seal

This deficiency effected two (2) of two (2) smoke compartments and all residents

Through observation during the survey, April 11, 2013, it was determined that the facility failed to maintain the fire resistance rating of the corridors.

During the walk through of the facility, with the Maintenance Director, the facility did not maintain the ceiling tiles as a smoke resitive throughout the facility. Areas throughout contained a wireless nurse call/paging system which the antennas protruded through the ceiling tiles. These areas were not sealed and did not maintain a smoke resistive corridor.
Note: The corridor walls do not continue to the ceiling above the drop ceiling, therefore the ceiling tiles must maintain a smoke resistive seperation.

This deficiency effected two (2) of two (2) smoke compartments and all residents

Through observation during the survey, April 11, 2013, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance Director, the corridor door from the emergency department patient care room would not latch into the frame. This door was a sliding type of door and the door did not contain any type of latching mechanism.

This deficiency had the potential to effect six (6) residents and one (1) smoke compartment.

Through observation during the survey, April 11, 2013, it was determined that the facility failed to maintain the smoke barriers.

During the walk through of the facility, with the Maintenance Director, one (1) smoke wall located adjacent to room #111 contained two (2) unsealed wire penetration without fire caulking or other approved method of maintaining the smoke rating of the wall per 19.3.7.3 and 8.3.2.

This deficiency effected two (2) of two (2) smoke compartments and all residents

Through observation during the survey, April 11, 2013, it was determined that the facility failed to maintain the hazardous areas.

During the walk-through of the facility with the Maintenance Director:
1) The storage room across from room #9 did not contain a self-closing device. This room contained a large amount of combustible items stored within the room.
2) The drop down door between the kitchen/dining room and the corridor was not attached to the fire alarm system and did not contain a fusible link.

This deficiency effected one (1) of two (2) smoke compartments

Through observation during the survey, April 11, 2013, it was determined that the facility failed to maintain a separation between the gift shop and the corridor.

During the walk through of the facility, with the Maintenance Director, the gift shop contained an open ceiling tile (used for a plenum return within an ceiling grid) was located within the gift shop. The wall between the gift shop and the corridor contained two (2) unsealed wire penetrations in the wall which prevented a positive smoke seal.

This deficiency effected one (1) of two (2) smoke compartments

Through record review during the survey, April 11, 2013, it was determined that the facility failed to conduct fire drills at least quarterly on each shift.

During the review of the facility records, with the Maintenance Director, documentation was not available to verify the facility conducted a fire drill on all shifts during the 2012 calendar year. Documentation could not be located for fire drills for;
1) Missing first (1st) shift during the first (1st) quarter of 2012
2) Missing second (2nd) shift during the second (2nd) quarter of 2012
3) Missing the second (2nd) shift during the fourth (4th) quarter of 2012

This deficiency effected two (2) of two (2) smoke compartments and all residents

Through observation during the survey, April 11, 2013, it was determined that the facility failed to install an automatic sprinkler system per NFPA 13.

During the walk through of the facility, with the Maintenance Director;
1) The sprinkler pump room contained a drop ceiling in which sixteen (16) ceiling tiles were missing. The sprinkler protection in this room were drop pendants that extended further than twelve inches (12")
2) One (1) sprinkler head in the "Data room" was installed as a pendant sprinkler and was installed at fourteen inches (14") from the ceiling.
3) Escutcheon plate was missing from the sprinkler heads located in the following areas:
a) Front entrance lobby
b) Radiology hallway
c) Labratory work area

This deficiency effected two (2) of two (2) smoke compartments and all residents

Through observation during the survey, April 11, 2013, it was determined the facility failed to test the automatic sprinkler system per NFPA 25.

During document review and a walk through of the facility, with the Maintenance Director, documentation was not available to indicate the sprinkler gauges were calibrated or replaced within the past five (5) years. The date on the two (2) sprinkler gauges at the backflow preventor stated the last calibration occured in September 2006.

This deficiency effected two (2) of two (2) smoke compartments and all residents

Through record review and staff interview during the survey, April 11, 2013, it was determined that the facility failed to inspect and professionally clean the kitchen exhaust system down to bare metal as required by NFPA 96.

During the review of the facility records, with the Maintenance Director, documentation indicated that the kitchen hood was professionaly clean in December 2012. During the visual inspection of the kitchen hood, the kitchen hood contained a large build up of greas at approximately six inches (6") into the duct work, indicating that the cleaning did not occur down to bare metal throughout the entire kitchen hood ductwork.

This deficiency effected one (1) smoke compartment

Through observation during the survey, April 11, 2013, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with the Maintenance Director, the facility contained a computer mounted onto the wall of the corridor. The computer is mounted on the corridor wall outside of the dining room and is located at forty-four inches (44") off of the floor and the keypad for the computer protrudes into the corridor by twelve inches (12").
Per 7.1.10 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use.

This deficiency effected one (1) smooke compartment

Through observation and record review during the survey, April 11, 2013, it was determined that the facility failed to provide decorations that comply with NFPA 701 in all areas.

During record review and walk through of the facility, with the Maintenance Director, decorations and loosely hanging fabrics located throughout the facility did not contain tags or markings showing that they met NFPA 701 requirements.
1) One (1) large quilt located at the front entrance
2) Fabric Valence located at the front entrance
3) Curtains located in the Bistro area

This deficiency effected two (2) of two (2) smoke compartment and all residents

Through observation and document review during the survey, April 11, 2013, it was determined that the facility failed to test the emergency generator per NFPA 110.

During record review, with the Maintenance Director, documentation indicated a monthly test of the generator under a load. The documentation indicated that a load was put on the generator of ninety (90) amps per month. This amperage load did not meet a thirty percent (30%) load of the generator and an annual load bank test could not be documented as being completed within the past year.
Per 1999 Edition of NFPA 101 section 21.2.9.2 and 7.9.2.3, and 1999 Edition of NFPA 110 6-4.2 and 6-4.2.2. 2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. "
And section 6.4.2.2 "Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours."

This deficiency effected Two (2) of two (2) smoke compartment and all residents

Through observation during the survey, April 11, 2013, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.

During the walkthrough of the facility, with the Maintenance Director, two (2) alcohol based hand rub dispensers (ABHR) were located above an electrical light switch.
1) Emergency Department room
2) Room #24

This deficiency effected two (2) rooms and a total of four (4) residents

Through observation, during the survey, April 11, 2013, it was determined that the facility failed to maintain the two hour fire resistance rating of the common wall between the Hospital and other occupancies.

During the walk through of the facility, with the Maintenance Director, the fire barrier walls contained unsealed wire penetrations in the following areas:
1) The two-hour (2) wall at the main conference room contained two (2) unsealed wire penetrations.
2) The two-hour (2) wall at the main conference room contained one (1) two inch by two inch (2"x2") piece of missing drywall
3) The two-hour (2) wall at the rehabilitation clinic contained drywall that went up to the corrugated metal deck. The space between the corrugated deck and the drywall did not contain a fire rated seal

This deficiency effected two (2) of two (2) smoke compartments and all residents

Through observation during the survey, April 11, 2013, it was determined that the facility failed to maintain the fire resistance rating of the corridors.

During the walk through of the facility, with the Maintenance Director, the facility did not maintain the ceiling tiles as a smoke resitive throughout the facility. Areas throughout contained a wireless nurse call/paging system which the antennas protruded through the ceiling tiles. These areas were not sealed and did not maintain a smoke resistive corridor.
Note: The corridor walls do not continue to the ceiling above the drop ceiling, therefore the ceiling tiles must maintain a smoke resistive seperation.

This deficiency effected two (2) of two (2) smoke compartments and all residents

Through observation during the survey, April 11, 2013, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance Director, the corridor door from the emergency department patient care room would not latch into the frame. This door was a sliding type of door and the door did not contain any type of latching mechanism.

This deficiency had the potential to effect six (6) residents and one (1) smoke compartment.

Through observation during the survey, April 11, 2013, it was determined that the facility failed to maintain the smoke barriers.

During the walk through of the facility, with the Maintenance Director, one (1) smoke wall located adjacent to room #111 contained two (2) unsealed wire penetration without fire caulking or other approved method of maintaining the smoke rating of the wall per 19.3.7.3 and 8.3.2.

This deficiency effected two (2) of two (2) smoke compartments and all residents

Through observation during the survey, April 11, 2013, it was determined that the facility failed to maintain the hazardous areas.

During the walk-through of the facility with the Maintenance Director:
1) The storage room across from room #9 did not contain a self-closing device. This room contained a large amount of combustible items stored within the room.
2) The drop down door between the kitchen/dining room and the corridor was not attached to the fire alarm system and did not contain a fusible link.

This deficiency effected one (1) of two (2) smoke compartments

Through observation during the survey, April 11, 2013, it was determined that the facility failed to maintain a separation between the gift shop and the corridor.

During the walk through of the facility, with the Maintenance Director, the gift shop contained an open ceiling tile (used for a plenum return within an ceiling grid) was located within the gift shop. The wall between the gift shop and the corridor contained two (2) unsealed wire penetrations in the wall which prevented a positive smoke seal.

This deficiency effected one (1) of two (2) smoke compartments

Through record review during the survey, April 11, 2013, it was determined that the facility failed to conduct fire drills at least quarterly on each shift.

During the review of the facility records, with the Maintenance Director, documentation was not available to verify the facility conducted a fire drill on all shifts during the 2012 calendar year. Documentation could not be located for fire drills for;
1) Missing first (1st) shift during the first (1st) quarter of 2012
2) Missing second (2nd) shift during the second (2nd) quarter of 2012
3) Missing the second (2nd) shift during the fourth (4th) quarter of 2012

This deficiency effected two (2) of two (2) smoke compartments and all residents

Through observation during the survey, April 11, 2013, it was determined that the facility failed to install an automatic sprinkler system per NFPA 13.

During the walk through of the facility, with the Maintenance Director;
1) The sprinkler pump room contained a drop ceiling in which sixteen (16) ceiling tiles were missing. The sprinkler protection in this room were drop pendants that extended further than twelve inches (12")
2) One (1) sprinkler head in the "Data room" was installed as a pendant sprinkler and was installed at fourteen inches (14") from the ceiling.
3) Escutcheon plate was missing from the sprinkler heads located in the following areas:
a) Front entrance lobby
b) Radiology hallway
c) Labratory work area

This deficiency effected two (2) of two (2) smoke compartments and all residents

Through observation during the survey, April 11, 2013, it was determined the facility failed to test the automatic sprinkler system per NFPA 25.

During document review and a walk through of the facility, with the Maintenance Director, documentation was not available to indicate the sprinkler gauges were calibrated or replaced within the past five (5) years. The date on the two (2) sprinkler gauges at the backflow preventor stated the last calibration occured in September 2006.

This deficiency effected two (2) of two (2) smoke compartments and all residents

Through record review and staff interview during the survey, April 11, 2013, it was determined that the facility failed to inspect and professionally clean the kitchen exhaust system down to bare metal as required by NFPA 96.

During the review of the facility records, with the Maintenance Director, documentation indicated that the kitchen hood was professionaly clean in December 2012. During the visual inspection of the kitchen hood, the kitchen hood contained a large build up of greas at approximately six inches (6") into the duct work, indicating that the cleaning did not occur down to bare metal throughout the entire kitchen hood ductwork.

This deficiency effected one (1) smoke compartment

Through observation during the survey, April 11, 2013, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with the Maintenance Director, the facility contained a computer mounted onto the wall of the corridor. The computer is mounted on the corridor wall outside of the dining room and is located at forty-four inches (44") off of the floor and the keypad for the computer protrudes into the corridor by twelve inches (12").
Per 7.1.10 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use.

This deficiency effected one (1) smooke compartment

Through observation and record review during the survey, April 11, 2013, it was determined that the facility failed to provide decorations that comply with NFPA 701 in all areas.

During record review and walk through of the facility, with the Maintenance Director, decorations and loosely hanging fabrics located throughout the facility did not contain tags or markings showing that they met NFPA 701 requirements.
1) One (1) large quilt located at the front entrance
2) Fabric Valence located at the front entrance
3) Curtains located in the Bistro area

This deficiency effected two (2) of two (2) smoke compartment and all residents

Through observation and document review during the survey, April 11, 2013, it was determined that the facility failed to test the emergency generator per NFPA 110.

During record review, with the Maintenance Director, documentation indicated a monthly test of the generator under a load. The documentation indicated that a load was put on the generator of ninety (90) amps per month. This amperage load did not meet a thirty percent (30%) load of the generator and an annual load bank test could not be documented as being completed within the past year.
Per 1999 Edition of NFPA 101 section 21.2.9.2 and 7.9.2.3, and 1999 Edition of NFPA 110 6-4.2 and 6-4.2.2. 2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. "
And section 6.4.2.2 "Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours."

This deficiency effected Two (2) of two (2) smoke compartment and all residents