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Based on observations made on July 26, 2010, the facility failed to assure that the fire doors in two-hour barriers closed and latched appropriately.

The findings include:

1. The one and one-half hour fire rated door in the two-hour fire barrier between the kitchen ice machine room and the main cooking area was exercised at 2:20 p.m. on July 26, 2010. The fire door did not close to a latch due to the top portion of the door binding on the door frame.

2. The one and one-half hour fire rated door in the two-hour fire barrier between the kitchen storage room and the main cooking area was exercised at 2:23 p.m. on July 26, 2010. The self-closure device on the fire door did not exert sufficient force to close and latch the door.

Based on observations made on July 26 and 27, 2010, the facility failed to maintain the fire and smoke resistance rating of wall assemblies in the building.

The findings include:

1. A cover plate was missing from an open abandoned junction box in the wall of the soiled linen room adjacent to the Hospital nurse's station area as observed at 3:16 p.m. on July 26, 2010.
Note: A cover plate was attached over the junction box and the opening after the observation was made and confirmed by the surveyor while on-site.

2. Blue communication wire had been run through the corridor wall assembly of the basement mechanical room that also accesses the generator and elevator control rooms. The penetration for this blue wire had not been sealed as observed at 4:49 p.m. on July 26, 2010.
Note: The open penetration was sealed with a fire rated caulk after the observation was made and confirmed by the surveyor while on-site.

3. A shelf or wall rack had been removed from a wall assembly in a storage closet located in the basement laundry suite as observed at 7:37 a.m. on July 27, 2010. The original anchor bolt holes for the shelf or rack had not been sealed.
Note: The open holes were sealed with non-combustible dry wall caulking after the observation was made and confirmed by the surveyor while on-site.

Based on observations made on July 26, 2010, the facility failed to assure that corridor doors in a fully sprinklered building were capable of resisting the passage of smoke.

The findings include:

1. The latching hardware on three doors on the main floor of the facility had been replaced with new hardware as observed between 1:55 p.m. and 2:00 p.m. on July 26, 2010. The bolt holes from the original hardware were not filled in to prevent the passage of smoke or to maintain the solid core design of the doors. The three doors were:
a) The door to the Infection Control office.
b) The door to the Patient Rehab room.
c) The door to the Chiropractor room.
Note: The open bolt holes on all three doors were sealed with wood putty after the observations were made and confirmed by the surveyor while on-site.

Based on observations made on July 26, 2010, the facility failed to maintain the fire resistive rating of smoke barriers.

The findings include:

The smoke barrier above the door way by the small seating area for the Emergency Room was examined at 3:35 p.m. on July 26, 2010. A small rectangular hole had been cut through the barrier to serve as a pass through for wiring and was not sealed.
Note: The rectangular hole was sealed with fire rated caulk after the observation was made and confirmed by the surveyor while on-site.

Based on review of quarterly sprinkler service reports and observations made on July 26, 2010, the facility failed to maintain the sprinkler system in accordance with the standards of NFPA 13.

The findings include:

Only new, listed sprinklers shall be used to replace existing sprinklers per section 2-4.1.2 of NFPA 25, 1998 edition.

1. The quarterly sprinkler service reports were reviewed at the facility on July 26, 2010. The report dated June 9, 2010, notes that two sidewall sprinklers located in the facility have been placed on a recall list. The sprinklers were located in:
a) The basement generator room.
b) The stairway used as the employee entrance and time clock access.
Both of these recalled sprinklers must be replaced with new sprinklers appropriately listed for those locations.

Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane below the sprinkler deflector or the top of storage shall be maintained with a minimum of 18" clearance per sections 5-5.5.3 and 5-5.6 of NFPA 13, 1999 edition.

2. The central storage room in the basement was examined at 4:35 p.m. on July 26, 2010. The storage room has shelving that extends into the center of the room. Items on these center shelves were observed to be stored within 18 inches of the sprinklers in this room.

Based on observations made on July 27, 2010, the facility failed to assure that all hanging drapes were flame resistant.

The findings include:

1. The Physical Therapy suite in the basement portion of the building was examined at 7:58 a.m. on July 27, 2010. Hanging drapes were in use in:
a) The Therapist office.
b) On the door to the pool.
c) On an exercise area window and door.
None of these fabric drapes had a label or tag attesting to their being flame resistant. There was no documentation that they had been treated with a flame retardant product made for fabric application.

Based on observations made on July 26, 2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70 and interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to the power strip.

A refrigerator and microwave in the Social Services office were both plugged directly into the same power strip as observed at 2:15 p.m. on July 26, 2010.
Note: The refrigerator and microwave were plugged directly into wall receptacles after the observation was made and confirmed by the surveyor while on-site.