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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces that had rooms open to the corridor with the required safe-guards. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undeterminable number of staff and visitors.

FINDINGS INCLUDE:
On 9-14-2010 at 2:45 pm surveyor #12187 observed in the 5th smoke compartment on the level one floor in room 112 , that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. This was also observed on the verification visit of November 1, 2010. The reception area is open to the corridor and it does not have 24 hour observation nor does it have a smoke detector coverage. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all of the PT and OT patients that the facility served, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 9-13-2010 at 2:30 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level in the corridor to PT area, that the clear and unobstructed width of the corridor was six feet. This was also observed on a verication visit on November 1, 2010. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.3. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). Corridors used only by others must be at least 44" wide.. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, that included all rooms sprinkled when the code required full sprinkling. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 9-13-2010 at 3:05 pm surveyor #12187 observed in the 2nd smoke compartment on the lower level in the elevator equipment room, that there was no sprinkler or approved alternative suppression measures. On November 1, 2010 during a verification visit, this was observed again. The building was required to be fully sprinkled because the building type II (0,0,0) is not permitted unless the building is fully sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.1 (exception). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services Director).