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Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Findings include:

While inspecting hazardous areas on December 10, 2013 at 11:30 a.m., the maintenance person and the the surveyor found the one hour enclosure for the gas fired Boiler Room had penetrations in the common wall to the hospital.

This deficient practice had the potential of effecting 1 of 3 smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1. and all states letter Ref: S&C -07-05.

Findings Include:

While inspecting exit access on December 10, 2013 at 12:30 p.m., the maintenance person and surveyor found 1 of the 4 required exits to be inaccessible. The exit from the 30 hallway lacked an all weather surface to the public way.

7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or
other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

7.1.6.4* Slip Resistance.
Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This deficient practices have the potential of effecting 1 of 3 smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Observation and interview reveals the facility does not monitor the operational status of the emergency generator in accordance with NFPA 110, 1999 Edition, Section 3-5.6, Remote Controls and Alarms and Table 3-5.5.2(d) Safety Indications and Shutdown, where there is no requirement for life support.

Findings include:

While inspecting the generator on December 10, 2013 at 12:00 p.m. the maintenance supervisor and surveyor observed the generator lacked remote common audible alarm powered by the storage battery as specified in Table 3-5.5.2(d), to monitor low coolant level. This remote alarm shall be located outside of the EPS Service Room at a work site readily observable by personnel..

Specific Code:

The National Electrical Code, 1999 Edition.
Article 517-40, Essential Electrical Systems for Nursing Homes and Limited Care Facilities.

This deficient practices have the potential of effecting the entire facility. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Findings include:

While inspecting hazardous areas on December 10, 2013 at 11:30 a.m., the maintenance person and the the surveyor found the one hour enclosure for the gas fired Boiler Room had penetrations in the common wall to the hospital.

This deficient practice had the potential of effecting 1 of 3 smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1. and all states letter Ref: S&C -07-05.

Findings Include:

While inspecting exit access on December 10, 2013 at 12:30 p.m., the maintenance person and surveyor found 1 of the 4 required exits to be inaccessible. The exit from the 30 hallway lacked an all weather surface to the public way.

7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or
other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

7.1.6.4* Slip Resistance.
Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This deficient practices have the potential of effecting 1 of 3 smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Observation and interview reveals the facility does not monitor the operational status of the emergency generator in accordance with NFPA 110, 1999 Edition, Section 3-5.6, Remote Controls and Alarms and Table 3-5.5.2(d) Safety Indications and Shutdown, where there is no requirement for life support.

Findings include:

While inspecting the generator on December 10, 2013 at 12:00 p.m. the maintenance supervisor and surveyor observed the generator lacked remote common audible alarm powered by the storage battery as specified in Table 3-5.5.2(d), to monitor low coolant level. This remote alarm shall be located outside of the EPS Service Room at a work site readily observable by personnel..

Specific Code:

The National Electrical Code, 1999 Edition.
Article 517-40, Essential Electrical Systems for Nursing Homes and Limited Care Facilities.

This deficient practices have the potential of effecting the entire facility. The maintenance supervisor and the administrator were notified during an exit conference.