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Based on facility tour and observation, review of facility documentation and staff interview and verification, the facility failed to ensure the building construction type and height met an approved construction type for the height, composition and use of the building. The hospital had a capacity of 346 certified beds with a census of 184 patients at the time of the PSR survey.

Findings included:

During the survey completed on 02/08/11 construction information was provided by the Staff F of the facility. Review of the information revealed the West building was first constructed in early 1900s and was added onto several times. Construction type included load bearing masonry, to steel post and beam, bar joists and some wood floor joist and wood roof joists. Attic spaces with exposed wood joists housed both mechanical and storage areas on two southerly wings. The West building was noted be approximately sixty percent sprinklered.

On 03/23/11, between 1:30 P.M. and 4:00 P.M. tour of the West building was conducted with Staff F and Staff G. Located on the fourth floor were two wings. One wing was identified to be storage and the other was a mechanical area. Observation of both areas revealed an attic type appearance with exposed wood construction at the roof and at the walls. The areas were provided automatic sprinkler protection and heat detection. The floors were noted to be concrete.

Review of the facility schematic indicated there was a 2 hour fire rated building separation between the mechanical room and the storage room and the reminder of the fourth floor. Observation above the ceiling tiles at the entrance to the mechanical room revealed a small space for visibility, approximately 4 inches in height by 5 feet in width. Exposed wood visible on the survey completed on 02/08/11, was covered with fire resistant material above the door frame.

Observation inside the mechanical room of the same 2 hour barrier wall revealed that due to pipes and other mechanical items access and visibility of the the two hour fire barrier was very limited. Staff F present verified that visibility of the fire wall from inside the mechanical room was very limited.

Staff F and G verified the exposed wood visible above the door frame outside the mechanical room was covered with fire resistive material since the 02/08/11 survey. Staff F and G also verified that due to the limited space available for observation, it was difficult to determine if the 2 hour fire wall was intact.

Further observation of the fourth floor revealed the presence of a locked geriatric psychiatric unit located between the two wings that were used as the mechanical room and and storage. Staff present on tour observed and verified the observations.

Continued observation of the West building did not reveal further observation of exposed wood in the construction of the building.

The facility contracted a local architect to observe and assess the mechanical and storage rooms that contained the exposed wood. The contracted architect completed a Fire Safety Evaluation System( FSES) on 03/23/11. Review of the completed FSES and interview of the architect on 03/25/11, did not clearly indicate the facility met the requirement.

Interview with Staff F on 03/25/11 revealed the facility planned to take pictures of the area for further review by Life Safety Code professionals.

Based on facility observation and staff interview and verification the facility failed to ensure that exit access was arranged so that exits were readily accessible at all times with regards to access to the public way. The hospital had a capacity of 346 certified beds with a census of 184 patients at the time of the survey. All patients, visitors and staff could potentially be affected.

Findings included:

On 03/22/11 through 03/25/11 observation of the sidewalk at the front of the facility revealed an exit door from the lower level of the hospital. Interview with Staff F and Staff G revealed that stairwell B was means of exit from the top floors of the East building to the level of discharge at the ground level.

Observation of stairwell B on 02/08/11 and 03/25/11 revealed that at the exit discharge there were 15 steps to climb to reach ground level. The steps lead to a landscaped area where there were small shrubs, trees and a grassy area. Observation from the landscaped area to the front sidewalk revealed a grassy, uneven area approximately 20 feet in distance.

Interview on 03/24 and 03/25/11 with Staff F and Staff G regarding the exit discharge verified there was no paved way to the sidewalk from the landscaped area at the front of the facility. Staff F stated that due to poor weather conditions a cement or paved way had not been completed for the exit to the sidewalk. Staff G indicated that framing and preparation for a concrete walkway was to be initiated in the next week.

Based on facility tour and observation, review of facility documentation and staff interview and verification, the facility failed to ensure interior walls and partitions in buildings were noncombustible or limited-combustible materials. The hospital had a capacity of 346 certified beds with a census of 184 patients at the time of the survey.

Findings included:

During the survey completed on 02/08/11 construction information was provided by the Staff F of the facility. Review of the information revealed the West building was first constructed in early 1900s and was added onto several times. Construction type included load bearing masonry, to steel post and beam, bar joists and some wood floor joist and wood roof joists. Attic spaces with exposed wood joists housed both mechanical and storage areas on two southerly wings. The West building was noted be approximately sixty percent sprinklered.

On 03/23/11, between 1:30 P.M. and 4:00 P.M. tour of the West building was conducted with Staff F and Staff G. Located on the fourth floor were two wings. One wing was identified to be storage and the other was a mechanical area. Observation of both areas revealed an attic type appearance with exposed wood construction at the roof and at the walls. The areas were provided automatic sprinkler protection and heat detection. The floors were noted to be concrete. The exposed wood ceiling and walls were noted to be not treated with fire retardant. Staff F and G verified the exposed wood in the mechanical room was not treated with fire retardant.

The facility contracted a local architect to observe and assess the mechanical and storage rooms that contained the exposed wood. The contracted architect completed a Fire Safety Evaluation System( FSES) on 03/23/11. Review of the completed FSES and interview of the architect on 03/25/11, did not clearly indicate the facility met the requirement.

Interview with Staff F on 03/25/11 revealed the facility planned to take pictures of the area for further review by Life Safety Code professionals.

1. Hazardous areas separated from other parts of the building by fire barriers having at least a one hour fire resistance rating or such areas are enclosed with partitions and doors and the area is provided with an automatic sprinkler system. High hazard areas are provided with both fire barriers and sprinkler systems as required by NFPA 39.3.2

This requirement was not met as evidenced by:

Based on facility tour and staff verification it was determined this facility failed to ensure all high hazardous areas were separated from other parts of the building with at least a one hour fire barrier and is equipped with a suppression system. The facility patient census at the time of the survey was 11. This could potentially affect all patient's, visitors and staff occupying the facility.


Findings included:

On 03/23/11, Staff F provided documentation that a contracted company had been secured to remove and store items observed in the facility basement during the survey completed on 02/08/11. Staff F verified that items had not been removed from the facility basement however were scheduled to be removed sometime the following week.

Tour of the basement portion of the facility took place on 03/24/11 at 10:30 AM with Staff G. During tour of the basement area observation was made of a very large quantity of combustible materials in the form of medical records, patient beds, chairs, cushions, wood pallets, carts and miscellaneous medical devices.

Observation was made of boxes of medical records and hospital department documentation estimated to be near a thousand, of which most but not all, were secured in five open fenced areas. Approximately two hundred were stacked on wood pallets and wood carts outside of the fenced area.

Beds, chairs, cushions and other medical devices were randomly placed throughout the basement area outside of the fenced in medical records areas. The basement was sprinklered, but lacked at least one hour fire resistance rating identified by the unprotected steel deck and girders.

Staff G verified that a minimal amount of combustible materials had been removed from the facility basement since the survey completed on 02/08/11.



2. Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1.

This requirement was not met as evidenced by:

Based on facility observation and staff verification it was determined the facility failed to ensure that safe exit access was available from an exit egress which leads to a paved common way. The facility patient census at the beginning of the survey was 11 . This could potentially affect all patient's, visitors and staff occupying this portion of the facility.

Findings included:

Tour of the facility took place on 03/24/11 at 10:30 AM with Staff G. During tour observation was made of two exit egresses from the facility located at the northeast corner of the building which lacked a continuous safe path to a paved common way.

Observation of the exit discharges for both locations revealed a small cement pad approximately 4 foot square. Between the cement pad and the paved public way was grassy, uneven ground estimated to be 50 to 60 feet in distance.

Interview of Staff G revealed the facility had planned to install concrete paths from the exit doors to the main public way. Staff G indicated the poor weather conditions had prevented installations as of 03/24/11. On 03/25/11 at 9:00 A.M., Staff G stated the contracted business was in progress of preparing the areas for pouring of concrete, possibly later in the day. Observation of the areas on 03/25/11 between 2:30 P.M. and 3:15 P.M. revealed the contracted company had one area prepared for concrete and one area was beginning to be prepared. Staff G indicated that due to cold temperatures forecasted for that day and the next, pouring of the concrete would have to be postponed.





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