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Based on observation and a review of documents, the facility fails to assure proper 2 hour fire rated separations to non-conforming buildings. The deficient practice compromises the fire-resistance rating of the walls and would not prevent the passage of fire or smoke to other areas of the building, affecting 16 of 22 smoke zones. The facility has a capacity of 132 with a census of 49 at the time of the survey.

FINDINGS INCLUDE:

During the portion of the tour conducted on 06/04/2010, between 10:00 a.m. and 4:30 p.m., the following is observed:

-- 1. The designated two-hour wall in the kitchen is a non-compliant wall due to a roll-down fire door in the cooking area of the kitchen and food storage/prep room.
-- 2. Unsealed gaps around wires, pipes and conduit were observed in the designated 2-hour rated wall in the kitchen. A masonry block is missing from the wall area separating the cooking area from a mechanical room.
-- 3. Unsealed gaps around pipes, wires, and conduit were observed in designated 2-hour rated walls above fire separation doors labeled 042, 068, 087.

During the portion of the tour conducted on 06/07/2010, between 9:30 a.m. and 3:00 p.m., the following is observed:

-- 1. Unsealed gaps around pipes, wires, or conduit were observed in designated 2-hour rated walls above fire separation doors labeled 101, 105, 135, 204, 206, 219.

Staff A, B and C were present, aware of the findings, and acknowledged the presence of communication openings and unsealed gaps in the designated fire walls.

Based upon observation and staff interview, the facility fails to assure that doors protecting and separating hazardous areas from other spaces are self-closing and latching. The deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 3 of 22 smoke zones. The facility has a capacity of 132 with a census of 49 at the time of the survey.

FINDINGS INCLUDE:

During the portion of the tour conducted on 06/04/2010, between 10:00 a.m. and 4:30 p.m., it is observed that corridor doors protecting the laundry failed to positively latch in their frames when tested.

Staff A, B and C were present and aware of the findings. Prior to the conclusion of the tour, the door latching mechanisms were adjusted for proper closure.

Based upon observation and staff interview, the facility fails to assure that cooking facilities are maintained and protected in accordance with 9.2.3. Failure to maintain grease removal devices increases the risk of fire and smoke to other areas of the building, affecting 2 of 22 smoke zones. The facility has a capacity of 132 with a census of 49 at the time of the survey.

FINDINGS INCLUDE:

During the portion of the tour conducted 06/04/2010, between 1:00 p.m. and 4:30 p.m., it is observed that grease filters in the hood system, located above cooking appliances in the cafeteria's serving area, are not properly installed and maintained, allowing a visible accumulation of grease on walls and in ductwork.

Staff A, B and C were present and aware of the findings. Prior to the conclusion of the survey, grease was removed from the filters/system and filters were properly installed.

Based upon observation and staff interview, the facility fails to assure that oxygen is stored in accordance with NFPA 99. Failure to separate and clearly identify full and empty oxygen cylinders could result in medical staff mistaking an empty cylinder for a full cylinder, affecting 3 of 22 smoke zones. The facility has a capacity of 132 with a census of 49 at the time of the survey.

FINDINGS INCLUDE:

During the portion of the tour conducted on 06/07/2010, between 9:30 a.m. and 3:00 p.m., it is observed that oxygen cylinders located in supply rooms for nurses' stations were stored in a mixed fashion, including empty cylinders in racks labeled "full".

Staff A, B and C were present, aware of the findings, and discussed options to assure proper storage of oxygen cylinders.

Based upon a review of records and staff interview, the facility fails to assure that generators are maintained and capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. The deficient practice reduces the reliability of the generator to perform as required in the event of an emergency, affecting all 22 of 22 smoke zones within the facility. The facility has a capacity of 132 with a census of 49 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/03/2010, between 1:00 p.m. and 4:30 p.m., a review of records for the last 4 quarters revealed:

-- 1. Test records for the 1250 KW generator reflect 3 occasions where transfer times were greater than 10 seconds.
-- 2. Test records for the 500 KW generator reflect 1 occasion where the transfer time was greater than 10 seconds.

Staff A, B and C were present and aware of the results of the record review. Staff B stated that repairs have been scheduled for the week of June 21, 2010.

Based on observation and a review of documents, the facility fails to assure proper 2 hour fire rated separations to non-conforming buildings. The deficient practice compromises the fire-resistance rating of the walls and would not prevent the passage of fire or smoke to other areas of the building, affecting 16 of 22 smoke zones. The facility has a capacity of 132 with a census of 49 at the time of the survey.

FINDINGS INCLUDE:

During the portion of the tour conducted on 06/04/2010, between 10:00 a.m. and 4:30 p.m., the following is observed:

-- 1. The designated two-hour wall in the kitchen is a non-compliant wall due to a roll-down fire door in the cooking area of the kitchen and food storage/prep room.
-- 2. Unsealed gaps around wires, pipes and conduit were observed in the designated 2-hour rated wall in the kitchen. A masonry block is missing from the wall area separating the cooking area from a mechanical room.
-- 3. Unsealed gaps around pipes, wires, and conduit were observed in designated 2-hour rated walls above fire separation doors labeled 042, 068, 087.

During the portion of the tour conducted on 06/07/2010, between 9:30 a.m. and 3:00 p.m., the following is observed:

-- 1. Unsealed gaps around pipes, wires, or conduit were observed in designated 2-hour rated walls above fire separation doors labeled 101, 105, 135, 204, 206, 219.

Staff A, B and C were present, aware of the findings, and acknowledged the presence of communication openings and unsealed gaps in the designated fire walls.

Based upon observation and staff interview, the facility fails to assure that doors protecting and separating hazardous areas from other spaces are self-closing and latching. The deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 3 of 22 smoke zones. The facility has a capacity of 132 with a census of 49 at the time of the survey.

FINDINGS INCLUDE:

During the portion of the tour conducted on 06/04/2010, between 10:00 a.m. and 4:30 p.m., it is observed that corridor doors protecting the laundry failed to positively latch in their frames when tested.

Staff A, B and C were present and aware of the findings. Prior to the conclusion of the tour, the door latching mechanisms were adjusted for proper closure.

Based upon observation and staff interview, the facility fails to assure that cooking facilities are maintained and protected in accordance with 9.2.3. Failure to maintain grease removal devices increases the risk of fire and smoke to other areas of the building, affecting 2 of 22 smoke zones. The facility has a capacity of 132 with a census of 49 at the time of the survey.

FINDINGS INCLUDE:

During the portion of the tour conducted 06/04/2010, between 1:00 p.m. and 4:30 p.m., it is observed that grease filters in the hood system, located above cooking appliances in the cafeteria's serving area, are not properly installed and maintained, allowing a visible accumulation of grease on walls and in ductwork.

Staff A, B and C were present and aware of the findings. Prior to the conclusion of the survey, grease was removed from the filters/system and filters were properly installed.

Based upon observation and staff interview, the facility fails to assure that oxygen is stored in accordance with NFPA 99. Failure to separate and clearly identify full and empty oxygen cylinders could result in medical staff mistaking an empty cylinder for a full cylinder, affecting 3 of 22 smoke zones. The facility has a capacity of 132 with a census of 49 at the time of the survey.

FINDINGS INCLUDE:

During the portion of the tour conducted on 06/07/2010, between 9:30 a.m. and 3:00 p.m., it is observed that oxygen cylinders located in supply rooms for nurses' stations were stored in a mixed fashion, including empty cylinders in racks labeled "full".

Staff A, B and C were present, aware of the findings, and discussed options to assure proper storage of oxygen cylinders.

Based upon a review of records and staff interview, the facility fails to assure that generators are maintained and capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. The deficient practice reduces the reliability of the generator to perform as required in the event of an emergency, affecting all 22 of 22 smoke zones within the facility. The facility has a capacity of 132 with a census of 49 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 06/03/2010, between 1:00 p.m. and 4:30 p.m., a review of records for the last 4 quarters revealed:

-- 1. Test records for the 1250 KW generator reflect 3 occasions where transfer times were greater than 10 seconds.
-- 2. Test records for the 500 KW generator reflect 1 occasion where the transfer time was greater than 10 seconds.

Staff A, B and C were present and aware of the results of the record review. Staff B stated that repairs have been scheduled for the week of June 21, 2010.