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Based on observations and interview, the facility failed to maintain the 4 hour fire barrier free of penetrations. This affects approximately 8 staff members due to the fact that the deficiency occurred in a non patient area (basement). The facility had a capacity of 213 patients and a census of 145 patients.

Finding include:

Observations and interview on 11-21-11, revealed a conduit penetration (approximately 1 inch in size) located in the 4 hour barrier in the basement that separates the Medical Air Area from the Garage Area.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to properly enclose stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors with 1 hour rated construction. This affects 1 smoke zone, affecting approximately 2 staff members only due to the effect that the deficiency occurred in a non patient area (Penthouse). The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed a penetration through drywall, around an I-Beam (approximately 3 inches in size) located on the east side of the stairwell, in Penthouse #3.

Maintenance Staff A and B verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to maintain 1 Smoke Barrier free of penetrations. This affects 1 smoke zone, affecting approximately 18 patients and 7 staff within the facility. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed a penetration (approximately 3/16 of an inch) located around a medical gas line that extends through the smoke barrier wall near Room 304.

Maintenance Staff A verified this observation at the time of the survey process.

(A.)
Based on observations and interview, the facility failed to maintain 1 hazardous room properly separated by failing to allow the door to properly close and latch. This affects approximately 10 patients and 6 staff members. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the door to the Crib and Jr. Bed Storage Room failed to close and latch properly into the door frame when tested.

Maintenance Staff A and B verified this observation at the time of the survey process.

(B.)
Based on observations and interview, the facility failed to maintain 1 hazardous room properly separated by failing to have a door equipped with an automatic door closing device. This affects approximately 10 patients and 6 staff members. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the door to the 2-J Wing Storage Room failed to be equipped with an automatic door closing device.

Maintenance Staff A and B verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to assure exit signs were properly displayed and visible throughout the facility at 1 location. This affects 1 smoke zone, affecting approximately 4 patients and approximately 6 staff members. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the facility failed to provide a visible illuminated exit sign to indicate the path of egress located in the Corridor, outside the back door of the Pharmacy.

Maintenance Staff A and B verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to comply with the fire drill requirements by failing to vary the times of their fire drills. This would affect all smoke zones, affecting all occupants and staff at the facility. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Record review and interview on 11-21-11, revealed the facility was not varying the times of their fire drills on 1 of 3 nursing shifts. During the 3rd nursing shift, within the past 12 months, the facility documented 4 fire drills within 11 minutes of each other. The 4 drills varied from 0630 hours during the 1st quarter year to 0641 hours during the last quarter year.

Maintenance Staff A and B verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by allowing sprinkler heads to have a foreign matter on them. This affects 3 smoke zones, affecting approximately 18 patients and 8 staff members. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11 revealed the following:

1. There were 2 quick response sprinkler heads located in the Labor Lounge had a lint like substance on it.

2. There was a quick response sprinkler head located in the Clean Stores of Digestive Health had a lint like substance on it.

3. There was 6 standard response sprinkler heads located in the Aerobics Room in the Basement of Rehabilitation that had a lint like substance on them.

Maintenance Supervisor A verified this observation at the time of the survey process.

(A.)
Based on observations and interview, the facility failed to maintain one portable fire extinguishers located in the facility in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition, by allowing the fire extinguisher to be undercharged. This affects 1 smoke zone, affecting approximately 8 patients and 4 staff members. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the fire extinguisher that was located near the main doors in the Heart and Vascular area was undercharged (the pressure needle was well below the acceptable green zone).

Maintenance Staff A and B verified this observation at the time of the survey process.

(B.)
Based on observations and interview, the facility failed to maintain one portable fire extinguishers located in the facility in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition, by failing to properly mount the fire extinguisher. This affects 1 smoke zone, affecting approximately 4 staff members only due to the fact that the deficiency occurred in a non-patient area (Pump Room). The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the fire extinguisher that was located in the Area G Pump Room failed to properly mounted.

Maintenance Staff A and B verified this observation at the time of the survey process.

Based on observations and interview, the facility is not maintaining an inspection schedule that is in compliance with the National Fire Protection Association (NFPA) 96, by failing to visually inspect the hood and duct suppression system on a monthly basis. This affects 1 smoke zone, affecting approximately 6 staff members only due to the fact that the deficiency occurred in a non-patient area (Kitchen). The facility had a license of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the facility failed to visually inspect the Hood and Duct Suppression System on a monthly basis.

Maintenance Staff A and B verified this observation at the time of the survey process.

Based on observations and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition by failing to properly maintain electrical breaker panel boxes . This affects 2 smoke zones, affecting approximately approximately 5 staff members only due to the fact that the deficiencies occurred in a non-patient area (Basement). The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the following:

1. There was an open gap in Electrical Panel NL5 that is located in Area G.

2. The circuit breakers in Electrical Panel NL1, located in the LA Electrical Room were not properly labeled

The Administrator and Maintenance Supervisor A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to maintain the 4 hour fire barrier free of penetrations. This affects approximately 8 staff members due to the fact that the deficiency occurred in a non patient area (basement). The facility had a capacity of 213 patients and a census of 145 patients.

Finding include:

Observations and interview on 11-21-11, revealed a conduit penetration (approximately 1 inch in size) located in the 4 hour barrier in the basement that separates the Medical Air Area from the Garage Area.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to properly enclose stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors with 1 hour rated construction. This affects 1 smoke zone, affecting approximately 2 staff members only due to the effect that the deficiency occurred in a non patient area (Penthouse). The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed a penetration through drywall, around an I-Beam (approximately 3 inches in size) located on the east side of the stairwell, in Penthouse #3.

Maintenance Staff A and B verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to maintain 1 Smoke Barrier free of penetrations. This affects 1 smoke zone, affecting approximately 18 patients and 7 staff within the facility. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed a penetration (approximately 3/16 of an inch) located around a medical gas line that extends through the smoke barrier wall near Room 304.

Maintenance Staff A verified this observation at the time of the survey process.

(A.)
Based on observations and interview, the facility failed to maintain 1 hazardous room properly separated by failing to allow the door to properly close and latch. This affects approximately 10 patients and 6 staff members. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the door to the Crib and Jr. Bed Storage Room failed to close and latch properly into the door frame when tested.

Maintenance Staff A and B verified this observation at the time of the survey process.

(B.)
Based on observations and interview, the facility failed to maintain 1 hazardous room properly separated by failing to have a door equipped with an automatic door closing device. This affects approximately 10 patients and 6 staff members. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the door to the 2-J Wing Storage Room failed to be equipped with an automatic door closing device.

Maintenance Staff A and B verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to assure exit signs were properly displayed and visible throughout the facility at 1 location. This affects 1 smoke zone, affecting approximately 4 patients and approximately 6 staff members. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the facility failed to provide a visible illuminated exit sign to indicate the path of egress located in the Corridor, outside the back door of the Pharmacy.

Maintenance Staff A and B verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to comply with the fire drill requirements by failing to vary the times of their fire drills. This would affect all smoke zones, affecting all occupants and staff at the facility. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Record review and interview on 11-21-11, revealed the facility was not varying the times of their fire drills on 1 of 3 nursing shifts. During the 3rd nursing shift, within the past 12 months, the facility documented 4 fire drills within 11 minutes of each other. The 4 drills varied from 0630 hours during the 1st quarter year to 0641 hours during the last quarter year.

Maintenance Staff A and B verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by allowing sprinkler heads to have a foreign matter on them. This affects 3 smoke zones, affecting approximately 18 patients and 8 staff members. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11 revealed the following:

1. There were 2 quick response sprinkler heads located in the Labor Lounge had a lint like substance on it.

2. There was a quick response sprinkler head located in the Clean Stores of Digestive Health had a lint like substance on it.

3. There was 6 standard response sprinkler heads located in the Aerobics Room in the Basement of Rehabilitation that had a lint like substance on them.

Maintenance Supervisor A verified this observation at the time of the survey process.

(A.)
Based on observations and interview, the facility failed to maintain one portable fire extinguishers located in the facility in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition, by allowing the fire extinguisher to be undercharged. This affects 1 smoke zone, affecting approximately 8 patients and 4 staff members. The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the fire extinguisher that was located near the main doors in the Heart and Vascular area was undercharged (the pressure needle was well below the acceptable green zone).

Maintenance Staff A and B verified this observation at the time of the survey process.

(B.)
Based on observations and interview, the facility failed to maintain one portable fire extinguishers located in the facility in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition, by failing to properly mount the fire extinguisher. This affects 1 smoke zone, affecting approximately 4 staff members only due to the fact that the deficiency occurred in a non-patient area (Pump Room). The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the fire extinguisher that was located in the Area G Pump Room failed to properly mounted.

Maintenance Staff A and B verified this observation at the time of the survey process.

Based on observations and interview, the facility is not maintaining an inspection schedule that is in compliance with the National Fire Protection Association (NFPA) 96, by failing to visually inspect the hood and duct suppression system on a monthly basis. This affects 1 smoke zone, affecting approximately 6 staff members only due to the fact that the deficiency occurred in a non-patient area (Kitchen). The facility had a license of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the facility failed to visually inspect the Hood and Duct Suppression System on a monthly basis.

Maintenance Staff A and B verified this observation at the time of the survey process.

Based on observations and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition by failing to properly maintain electrical breaker panel boxes . This affects 2 smoke zones, affecting approximately approximately 5 staff members only due to the fact that the deficiencies occurred in a non-patient area (Basement). The facility had a capacity of 213 patients and a census of 145 patients.

Findings include:

Observations and interview on 11-21-11, revealed the following:

1. There was an open gap in Electrical Panel NL5 that is located in Area G.

2. The circuit breakers in Electrical Panel NL1, located in the LA Electrical Room were not properly labeled

The Administrator and Maintenance Supervisor A verified this observation at the time of the survey process.