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Based on observations the facility failed to provide the required corridor walls with 30 minute fire resistance rating in accordance with 19.3.6.1, 19.3.6.2, 18.3.6.4, 19.3.6.5. This deficient practice has the potential of affecting 2 of 3 smoke compartments and all 14 patients in the facility on the day of survey.

Finding include:

While inspecting corridor walls on October 22, 2015 at 10:30 a.m., observation revealed the corridor walls had the following unsealed penetrations:

1. Corridor wall near Patient Room 42 had an unsealed penetrations at around electrical panel.

2. Corridor wall near Electrical Room had 2 broken out portions of masonry from the result of the newly installed medical gases system.

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 NFPA 101 section 8.3, 19.3.7.3, 19.3.7.5. These deficient practices have the potential of affecting 2 of 3 smoke compartments. This deficient practice has the potential to affect 2 of 14 residents in the facility at the day/time of survey.

Finding include:

While inspecting smoke barrier walls on October 22, 2015 at 10:30 a.m., observation revealed the smoke barrier walls had the following unsealed penetrations in the following area:

1. Smoke barrier wall near Patient Room 16 has unsealed penetration above ceiling.

2. Smoke barrier wall separating Hospital from the Nursing Home has two (2) unsealed penetrations above the ceiling.

The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to properly protect hazardous areas in accordance to NFPA 101 section 19.3.2.1. This deficient practice affected the entire facility on the day of the survey.

Findings include:

On October 22, 2015 at 11:35 a.m., observation revealed the ceiling and walls in the Mechanical Room near the Visitors Entrance was incapable of resisting smoke due to numerous openings and penetrations.

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 readily accessible exit access and clear and unobstructed corridor serving in an existing facility in accordance to NFPA 101 19.2.3.3. This deficient practice has the potential of affecting 1 of 3 smoke compartments and all 14 patents on the day of survey.

Findings Include:

During the facility inspection of the means of egress on October 22, 2015 at 12:35 a.m., observation revealed the hall/ corridor near the Clinic Area was obstructed with chairs and waiting patients overflowing into the hall from the Clinic.

The administrator as well as the maintenance director was notified during the survey as well as the exit conference.

Based on observations, the facility failed to have a properly installed
fire alarm system as required by NFPA72 2-8.2.2. This condition affected one (1) of three (3) smoke compartments and all 14 residents in the facility at the time of survey.

Findings Include:

On October 22, 2015 at 11:30 a.m., observation revealed the manual pull station was mounted 45 feet from the Visitors Entrance/ Exit.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

NFPA 72 section 2-8.2.2
Manual fire alarm boxes shall be located within 5 ft (1.5 m) of the exit doorway opening at each exit on each floor.

Based on observation and testing, the facility failed to provide the properly located strode/horn fire alarm systems in accordance to NFPA 72 Section 1-5.6. This condition affected 1 of 5 smoke compartments. The facility had the capacity for 25 beds with a census of 14 on the day of survey.

Findings include:

On October 22, 2015 at 11:50 a.m., observation revealed emergency strobes lights and horn strobes were not installed in 3 of 5 fire zones of the facility.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations the facility failed to provide the required corridor walls with 30 minute fire resistance rating in accordance with 19.3.6.1, 19.3.6.2, 18.3.6.4, 19.3.6.5. This deficient practice has the potential of affecting 2 of 3 smoke compartments and all 14 patients in the facility on the day of survey.

Finding include:

While inspecting corridor walls on October 22, 2015 at 10:30 a.m., observation revealed the corridor walls had the following unsealed penetrations:

1. Corridor wall near Patient Room 42 had an unsealed penetrations at around electrical panel.

2. Corridor wall near Electrical Room had 2 broken out portions of masonry from the result of the newly installed medical gases system.

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 NFPA 101 section 8.3, 19.3.7.3, 19.3.7.5. These deficient practices have the potential of affecting 2 of 3 smoke compartments. This deficient practice has the potential to affect 2 of 14 residents in the facility at the day/time of survey.

Finding include:

While inspecting smoke barrier walls on October 22, 2015 at 10:30 a.m., observation revealed the smoke barrier walls had the following unsealed penetrations in the following area:

1. Smoke barrier wall near Patient Room 16 has unsealed penetration above ceiling.

2. Smoke barrier wall separating Hospital from the Nursing Home has two (2) unsealed penetrations above the ceiling.

The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to properly protect hazardous areas in accordance to NFPA 101 section 19.3.2.1. This deficient practice affected the entire facility on the day of the survey.

Findings include:

On October 22, 2015 at 11:35 a.m., observation revealed the ceiling and walls in the Mechanical Room near the Visitors Entrance was incapable of resisting smoke due to numerous openings and penetrations.

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 readily accessible exit access and clear and unobstructed corridor serving in an existing facility in accordance to NFPA 101 19.2.3.3. This deficient practice has the potential of affecting 1 of 3 smoke compartments and all 14 patents on the day of survey.

Findings Include:

During the facility inspection of the means of egress on October 22, 2015 at 12:35 a.m., observation revealed the hall/ corridor near the Clinic Area was obstructed with chairs and waiting patients overflowing into the hall from the Clinic.

The administrator as well as the maintenance director was notified during the survey as well as the exit conference.

Based on observations, the facility failed to have a properly installed
fire alarm system as required by NFPA72 2-8.2.2. This condition affected one (1) of three (3) smoke compartments and all 14 residents in the facility at the time of survey.

Findings Include:

On October 22, 2015 at 11:30 a.m., observation revealed the manual pull station was mounted 45 feet from the Visitors Entrance/ Exit.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

NFPA 72 section 2-8.2.2
Manual fire alarm boxes shall be located within 5 ft (1.5 m) of the exit doorway opening at each exit on each floor.

Based on observation and testing, the facility failed to provide the properly located strode/horn fire alarm systems in accordance to NFPA 72 Section 1-5.6. This condition affected 1 of 5 smoke compartments. The facility had the capacity for 25 beds with a census of 14 on the day of survey.

Findings include:

On October 22, 2015 at 11:50 a.m., observation revealed emergency strobes lights and horn strobes were not installed in 3 of 5 fire zones of the facility.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.