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Based on observation and interview, the facility did not provide a two-hour occupancy separation wall that was sealed at wall penetrations, and all butt joints were not fully embedded in joint compound to a two-hour rating. This deficiency occurred in 1 location of the occupancy separation wall between the clinic and the hospital, and had the potential to affect all 25 of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 05/16/2011 at 1:16 pm surveyor #14105 observed at the east wall of the physicians lounge, that the separation wall was not constructed to have a 2-hour fire resistance rating because all of the tape at the butt joints were not completely embedded in joint compound and a 3/4" metal conduit was not fire safed within the annular space of the penetration. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

Based on observation and interview, the facility did not provide smoke-tight corridor walls along the corridor system. Several paired sets of doors into the corridor system were not sealed at the meeting edge of the door leafs to prevent smoke from entering the exit access system. This deficiency occurred in 4 locations of the corridor wall and had the potential to affect all 25 of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 05/16/2011 at 1:57 PM surveyor #14105 observed that the paired doors from the SCU suite into the north corridor wing were not sealed with an astragal to prevent the passage of smoke into the corridor system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

2. On 05/16/2011 at 3:44 PM surveyor #14105 observed that the west set of paired doors from the surgery suite into the corridor south of this suite were not sealed with an astragal to prevent the passage of smoke into the corridor system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

3. On 05/16/2011 at 3:47 PM surveyor #14105 observed that the east set of paired doors from the surgery suite into the corridor south of this suite were not sealed with an astragal to prevent the passage of smoke into the corridor system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

4. On 05/16/2011 at 3:59 PM surveyor #14105 observed that the paired doors from the Wellness into the corridor south of this suite were not sealed with an astragal to prevent the passage of smoke into the corridor system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

Based on observation and interview, the facility did not provide proper exit signs to direct occupants to the nearest exit within the facility. This deficiency occurred in one of the passage ways of this building and had the potential to affect several of the 25 patients that the facility was licensed to serve, as well as many as 10 staff and visitors.

FINDINGS INCLUDE:
On 05/16/2011 at 1:01 PM surveyor #14105 observed that the passage within the Administration suite did not have any exit sign at either end of this passageway. It was very difficult to determine which end of this passage was closest to the exit access corridor system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

Based on observation and interview, the facility did not provide one-hour rated smoke-compartment walls within the facility. The half-hour rated smoke compartment walls had taped butt joints that were not completely embedded within joint compound and the screwheads within the fields of these walls were not covered with joint compound to meet the minimum standards of a half-hour rated fire/smoke barrier. This deficiency occurred along all of the walls of the smoke compartment walls through out this building and had the potential to affect all 25 of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 05/16/2011 at 1:35 PM surveyor #14105 observed that the north side of the smoke compartment wall in the care managers office did not have the screwheads covered with joint compound to provide a half-hour rated fire/smoke barrier. The screwheads at all observed locations of the smoke compartment wall were not covered with joint compound throughout the facility. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

2. On 05/16/2011 at 1:44 PM surveyor #14105 observed that the left door leaf in the smoke compartment opening did not latch positively. Positive latching mechanisms were provided by the original design and the closer did not pull the leaf to a position so the latch could engage positively. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

Based on observation and interview, the facility did not provide properly constructed fire barrier, 45-minute rated doors and did not enclose large areas of combustible materials within the facility with one-hour fire barriers. These deficiencies occurred within all four of the four smoke compartments within this building and had the potential to affect all 25 of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 05/16/2011 at 1:40 PM surveyor #14105 observed that the 3/4" conduit was not fire safed within the annular space to meet the minimum requirements of a one-hour fire barrier. This deficient condition occurred on the back wall away from the entry door to the Clean Utility room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

Based on observation and interview, the facility did not provide a sprinkler system that was continuously maintained in a reliable operating condition and was inspected periodically to ensure that the system and its components met code minimum standards for their facility. Deficiencies occurred in several locations of this building and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as staff and visitors.

FINDINGS INCLUDE:
1. On 05/16/2011 at 1:08 PM surveyor #14105 observed that the sprinkler head within the telecommunication closet near the front desk was not sealed with an escutcheon. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.6 which references section 4.16.12.1 which states that whenever a system is required for compliance to this code, such system shall thereafter be continuously maintained in accordance to NFPA requirements. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

2. On 05/16/2011 at 2:23 PM surveyor #14105 observed that the sprinkler head within the telecommunications room across the corridor from the ED was installed for a lay-in ceiling system, there was no lay-in ceiling present. The sprinkler head was located greater than 22" from the structural deck of this room. This observed situation was not compliant with NFPA 101 (2000 Edition) 19.7.6 that references section 4.16.12.1 which states that whenever a system is required for compliance to this code, such system shall thereafter be continuously maintained in accordance to NFPA requirements. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

3. On 05/16/2011 at 3:16 PM surveyor #14105 observed within the main electrical distribution room for the normal and emergency switchgear that sprinkler heads were installed within the space and the room was not constructed to a two-hour rated enclosure. The sprinkler head discharge was not shielded from any of the gear for either system. This observed situation was not compliant with NFPA 101 (2000 Edition) 19.3.5.1 which references further guidance in 9.7 and 9.7.1.1. NFPA 13 is referenced within 9.7.1.1; section 5-13.11 states that hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

Based on observation and interview, the facility did not provide a heating and ventilation and air conditioning system complaint to section 19.5.2.1 which references section 9.2. Section 9.2.1 states that the heating and ventilation system shall be in accordance to NFPA 90A . These deficiencies occurred in several locations within the hospital and had the potential to affect all 25 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 05/17/2011 at 8:15 AM during paper review it was stated by staff J that the round ducts throughout the faciltiy did not have access panels cut into them for maintenance and observation of the fire or smoke dampers within the duct work. This observed situation was not compliant with NFPA 101 (2000 edition) Sections19.5.2.1 and 9.2.1 which references NFPA 90A. In NFPA 90A in Section 5.4.8 Maintenance 5.4.8.1 directs to NFPA 80 for fire dampers and 5.4.8.2 directs to NFPA 105 smoke dampers. Section 19.2.3 of NFPA 80 requires an access panel for a fire damper. In Section 6.3.2 of NFPA 105 requires an access panel for a smoke damper. The deficiency was confirmed at the time of discovery by a concurrent interview with staff B and J.

Based on observation and interview, the facility had miscellaneous non-compliant elements within this building. The deficiencies occurred in several locations of the hospital, and had the potential to affect all 25 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 05/16/2011 at 3:13 PM surveyor #14105 observed in the main electrical distribution room for the emergency and normal electrical systems that part of the room was being used for general storage. This observed situation was not compliant with NFPA 101 (2000 edition) 19.5.2.1 and 9.1.2. NFPA 70 within article 110 (II)(F) states that all switchboards, panelboards, and distribution boards shall be located in dedicated spaces. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

Based on observation and interview, the facility did not provide a two-hour occupancy separation wall that was sealed at wall penetrations, and all butt joints were not fully embedded in joint compound to a two-hour rating. This deficiency occurred in 1 location of the occupancy separation wall between the clinic and the hospital, and had the potential to affect all 25 of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 05/16/2011 at 1:16 pm surveyor #14105 observed at the east wall of the physicians lounge, that the separation wall was not constructed to have a 2-hour fire resistance rating because all of the tape at the butt joints were not completely embedded in joint compound and a 3/4" metal conduit was not fire safed within the annular space of the penetration. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

Based on observation and interview, the facility did not provide smoke-tight corridor walls along the corridor system. Several paired sets of doors into the corridor system were not sealed at the meeting edge of the door leafs to prevent smoke from entering the exit access system. This deficiency occurred in 4 locations of the corridor wall and had the potential to affect all 25 of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 05/16/2011 at 1:57 PM surveyor #14105 observed that the paired doors from the SCU suite into the north corridor wing were not sealed with an astragal to prevent the passage of smoke into the corridor system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

2. On 05/16/2011 at 3:44 PM surveyor #14105 observed that the west set of paired doors from the surgery suite into the corridor south of this suite were not sealed with an astragal to prevent the passage of smoke into the corridor system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

3. On 05/16/2011 at 3:47 PM surveyor #14105 observed that the east set of paired doors from the surgery suite into the corridor south of this suite were not sealed with an astragal to prevent the passage of smoke into the corridor system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

4. On 05/16/2011 at 3:59 PM surveyor #14105 observed that the paired doors from the Wellness into the corridor south of this suite were not sealed with an astragal to prevent the passage of smoke into the corridor system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

Based on observation and interview, the facility did not provide proper exit signs to direct occupants to the nearest exit within the facility. This deficiency occurred in one of the passage ways of this building and had the potential to affect several of the 25 patients that the facility was licensed to serve, as well as many as 10 staff and visitors.

FINDINGS INCLUDE:
On 05/16/2011 at 1:01 PM surveyor #14105 observed that the passage within the Administration suite did not have any exit sign at either end of this passageway. It was very difficult to determine which end of this passage was closest to the exit access corridor system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

Based on observation and interview, the facility did not provide one-hour rated smoke-compartment walls within the facility. The half-hour rated smoke compartment walls had taped butt joints that were not completely embedded within joint compound and the screwheads within the fields of these walls were not covered with joint compound to meet the minimum standards of a half-hour rated fire/smoke barrier. This deficiency occurred along all of the walls of the smoke compartment walls through out this building and had the potential to affect all 25 of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 05/16/2011 at 1:35 PM surveyor #14105 observed that the north side of the smoke compartment wall in the care managers office did not have the screwheads covered with joint compound to provide a half-hour rated fire/smoke barrier. The screwheads at all observed locations of the smoke compartment wall were not covered with joint compound throughout the facility. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

2. On 05/16/2011 at 1:44 PM surveyor #14105 observed that the left door leaf in the smoke compartment opening did not latch positively. Positive latching mechanisms were provided by the original design and the closer did not pull the leaf to a position so the latch could engage positively. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

Based on observation and interview, the facility did not provide properly constructed fire barrier, 45-minute rated doors and did not enclose large areas of combustible materials within the facility with one-hour fire barriers. These deficiencies occurred within all four of the four smoke compartments within this building and had the potential to affect all 25 of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
1. On 05/16/2011 at 1:40 PM surveyor #14105 observed that the 3/4" conduit was not fire safed within the annular space to meet the minimum requirements of a one-hour fire barrier. This deficient condition occurred on the back wall away from the entry door to the Clean Utility room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

Based on observation and interview, the facility did not provide a sprinkler system that was continuously maintained in a reliable operating condition and was inspected periodically to ensure that the system and its components met code minimum standards for their facility. Deficiencies occurred in several locations of this building and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as staff and visitors.

FINDINGS INCLUDE:
1. On 05/16/2011 at 1:08 PM surveyor #14105 observed that the sprinkler head within the telecommunication closet near the front desk was not sealed with an escutcheon. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.6 which references section 4.16.12.1 which states that whenever a system is required for compliance to this code, such system shall thereafter be continuously maintained in accordance to NFPA requirements. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

2. On 05/16/2011 at 2:23 PM surveyor #14105 observed that the sprinkler head within the telecommunications room across the corridor from the ED was installed for a lay-in ceiling system, there was no lay-in ceiling present. The sprinkler head was located greater than 22" from the structural deck of this room. This observed situation was not compliant with NFPA 101 (2000 Edition) 19.7.6 that references section 4.16.12.1 which states that whenever a system is required for compliance to this code, such system shall thereafter be continuously maintained in accordance to NFPA requirements. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

3. On 05/16/2011 at 3:16 PM surveyor #14105 observed within the main electrical distribution room for the normal and emergency switchgear that sprinkler heads were installed within the space and the room was not constructed to a two-hour rated enclosure. The sprinkler head discharge was not shielded from any of the gear for either system. This observed situation was not compliant with NFPA 101 (2000 Edition) 19.3.5.1 which references further guidance in 9.7 and 9.7.1.1. NFPA 13 is referenced within 9.7.1.1; section 5-13.11 states that hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.

Based on observation and interview, the facility did not provide a heating and ventilation and air conditioning system complaint to section 19.5.2.1 which references section 9.2. Section 9.2.1 states that the heating and ventilation system shall be in accordance to NFPA 90A . These deficiencies occurred in several locations within the hospital and had the potential to affect all 25 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 05/17/2011 at 8:15 AM during paper review it was stated by staff J that the round ducts throughout the faciltiy did not have access panels cut into them for maintenance and observation of the fire or smoke dampers within the duct work. This observed situation was not compliant with NFPA 101 (2000 edition) Sections19.5.2.1 and 9.2.1 which references NFPA 90A. In NFPA 90A in Section 5.4.8 Maintenance 5.4.8.1 directs to NFPA 80 for fire dampers and 5.4.8.2 directs to NFPA 105 smoke dampers. Section 19.2.3 of NFPA 80 requires an access panel for a fire damper. In Section 6.3.2 of NFPA 105 requires an access panel for a smoke damper. The deficiency was confirmed at the time of discovery by a concurrent interview with staff B and J.

Based on observation and interview, the facility had miscellaneous non-compliant elements within this building. The deficiencies occurred in several locations of the hospital, and had the potential to affect all 25 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 05/16/2011 at 3:13 PM surveyor #14105 observed in the main electrical distribution room for the emergency and normal electrical systems that part of the room was being used for general storage. This observed situation was not compliant with NFPA 101 (2000 edition) 19.5.2.1 and 9.1.2. NFPA 70 within article 110 (II)(F) states that all switchboards, panelboards, and distribution boards shall be located in dedicated spaces. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff B and J.