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Based upon observations made in the presence of the plant manager on 6/29/10, it was determined that the facility did not maintain corridors to resist passage of smoke.

Findings include:

1. The OR had a 2 " opening around the communication lines above the ceiling from the corridor and the fire separation which would not resist the passage of smoke and fire.
2. The step down recovery area had a 4 " x 4 " opening above the ceiling from the corridor and the fire separation which would not resist the passage of smoke and fire.
3. The two hour fire separation doors from the ER when allowed to self-close did not positive latch to resist the passage of smoke and fire.

Based upon observations made in the presence of the plant manager on 6/29/10, it was determined that the facility did not maintain vertical opening doors to resist passage of smoke.

Findings include:

The doors to the stairwell from the basement to the main level did not self-close and positively latch to resist smoke and fire on both levels.

Based upon observations made in the presence of the plant manager on 6/29/10, it was determined that the facility did not maintain corridors doors to resist passage of smoke.

Findings include:

The two hour fire separation doors from the ER when allowed to self-close did not positive latch to resist the passage of smoke and fire.

Based upon observations made in the presence of the plant manager on 6/29/10, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility.

Findings include:

1. The soiled utility room door by 121 did not positive latch when allowed closed to resist the passage of smoke.
2. The electrical/mechanical room by medical surgical room had a 1 " opening around utility lines that would not resist the passage of smoke.
3. The purchasing/central supply room had a 2 " wall opening on west wall.

Based upon observations made in the presence of the plant manager on 6/29/10, it was determined that the facility did not maintain exit to be readily accessible at all times.

Findings include:

The front lobby exit doors had hooked latch dead bolt locks on the door. When tested the doors did not break away to allow egress from the building.

Based upon observation of fire drill documentation made in the presence of the plant manager on 6/29/10, it was determined that the facility did not conduct fire drills at one per quarter per shift in accordance with Life Safety Code regulations.

Findings include:

The facility did not conduct a fire drill for 1st quarter graveyard shift and 2nd quarter afternoon shift during the previous 12 month period.

Based upon observations made in the presence of the plant manager on 6/26/10, it was determined that the facility did not maintain fire sprinkler heads and equipment in accordance with NFPA 13 and per CMS regulations.

Findings include:

The fire sprinkler heads to the purchasing/central supply room and dietary office were missing escutcheon rings.

Based upon observations made in the presence of the plant manager on 6/29/10, it was determined that the facility did not maintain the HVAC fire damper in accordance with NFPA 90 regulations.

Findings include:

The fire dampers by the dining area had communication cable installed through the damper which would not allow the damper to function correctly to resist the passage of smoke.

Based upon observations made in the presence of the plant manager on 6/26/10, it was determined that the facility did not maintain the generator set in accordance with NFPA 99, NFPA 110 and per CMS regulations.

Findings include:

The one of two remote annunciator panel lab tests failed when tested, during survey.

Based upon observations made in the presence of the plant manager on 6/29/10, it was determined that the facility did not maintain corridors to resist passage of smoke.

Findings include:

1. The OR had a 2 " opening around the communication lines above the ceiling from the corridor and the fire separation which would not resist the passage of smoke and fire.
2. The step down recovery area had a 4 " x 4 " opening above the ceiling from the corridor and the fire separation which would not resist the passage of smoke and fire.
3. The two hour fire separation doors from the ER when allowed to self-close did not positive latch to resist the passage of smoke and fire.

Based upon observations made in the presence of the plant manager on 6/29/10, it was determined that the facility did not maintain vertical opening doors to resist passage of smoke.

Findings include:

The doors to the stairwell from the basement to the main level did not self-close and positively latch to resist smoke and fire on both levels.

Based upon observations made in the presence of the plant manager on 6/29/10, it was determined that the facility did not maintain corridors doors to resist passage of smoke.

Findings include:

The two hour fire separation doors from the ER when allowed to self-close did not positive latch to resist the passage of smoke and fire.

Based upon observations made in the presence of the plant manager on 6/29/10, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility.

Findings include:

1. The soiled utility room door by 121 did not positive latch when allowed closed to resist the passage of smoke.
2. The electrical/mechanical room by medical surgical room had a 1 " opening around utility lines that would not resist the passage of smoke.
3. The purchasing/central supply room had a 2 " wall opening on west wall.

Based upon observations made in the presence of the plant manager on 6/29/10, it was determined that the facility did not maintain exit to be readily accessible at all times.

Findings include:

The front lobby exit doors had hooked latch dead bolt locks on the door. When tested the doors did not break away to allow egress from the building.

Based upon observation of fire drill documentation made in the presence of the plant manager on 6/29/10, it was determined that the facility did not conduct fire drills at one per quarter per shift in accordance with Life Safety Code regulations.

Findings include:

The facility did not conduct a fire drill for 1st quarter graveyard shift and 2nd quarter afternoon shift during the previous 12 month period.

Based upon observations made in the presence of the plant manager on 6/26/10, it was determined that the facility did not maintain fire sprinkler heads and equipment in accordance with NFPA 13 and per CMS regulations.

Findings include:

The fire sprinkler heads to the purchasing/central supply room and dietary office were missing escutcheon rings.

Based upon observations made in the presence of the plant manager on 6/29/10, it was determined that the facility did not maintain the HVAC fire damper in accordance with NFPA 90 regulations.

Findings include:

The fire dampers by the dining area had communication cable installed through the damper which would not allow the damper to function correctly to resist the passage of smoke.

Based upon observations made in the presence of the plant manager on 6/26/10, it was determined that the facility did not maintain the generator set in accordance with NFPA 99, NFPA 110 and per CMS regulations.

Findings include:

The one of two remote annunciator panel lab tests failed when tested, during survey.