HospitalInspections.org

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. This condition has the potential to affect about 50% of the residents and staff.

Findings include:

While inspecting smoke barrier walls on October 29, 2013 at 10:30 a.m., the maintenance supervisor and the surveyor observed the smoke barrier located in the corridor next to the lobby had a penetration over the expansion joint.

This deficient practice has the potential of affecting 2 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the 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 doors on October 29, 2013 at 11:30 a.m., the maintenance supervisor and the surveyor observed a door in the smoke barrier walls, located next to the Front Lobby did not close completely.

This deficient practice has the potential of affecting 2 of 3 smoke compartments. 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 October 29, 2013 at 11:00 a.m., the maintenance person and the surveyor found the one hour enclosure for the gas fired water heater had 4 penetration around piping that went through the 1 hour rated wall.

This deficient practice has the potential of affecting 1 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building. This condition affected 10% of the residents and staff of the building.

Findings include:

While inspecting the sprinkler system on October 29, 2013 at 11:45 p.m., the maintenance person and surveyor found a sprinkler head blocked by an exit sign on the patient corridor.

This deficient practice has the potential of affecting 1 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the 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. This condition has the potential to affect about 50% of the residents and staff.

Findings include:

While inspecting smoke barrier walls on October 29, 2013 at 10:30 a.m., the maintenance supervisor and the surveyor observed the smoke barrier located in the corridor next to the lobby had a penetration over the expansion joint.

This deficient practice has the potential of affecting 2 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the 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 doors on October 29, 2013 at 11:30 a.m., the maintenance supervisor and the surveyor observed a door in the smoke barrier walls, located next to the Front Lobby did not close completely.

This deficient practice has the potential of affecting 2 of 3 smoke compartments. 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 October 29, 2013 at 11:00 a.m., the maintenance person and the surveyor found the one hour enclosure for the gas fired water heater had 4 penetration around piping that went through the 1 hour rated wall.

This deficient practice has the potential of affecting 1 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building. This condition affected 10% of the residents and staff of the building.

Findings include:

While inspecting the sprinkler system on October 29, 2013 at 11:45 p.m., the maintenance person and surveyor found a sprinkler head blocked by an exit sign on the patient corridor.

This deficient practice has the potential of affecting 1 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.