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Based on observation and interview, the facility had a room that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the safety of 4 patients, staff and visitors, if smoke were allowed to enter the exit access corridors making it untenable.

Findings include:

On facility tour between 12:30 PM and 3:30 PM on 9/02/2011, it was observed that the IT office did not have a door and was open to the corridor not meeting the requirements with LSC (00), Section 19.3.6.3.2.


This deficient practice was verified by the Safety Officer.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 19, Section 19.3.5. and Chapter 9, Section 9.7. This deficient pratice could affect all 4 patients, visitors, and staff.

FINDINGS INCLUDE:

On facility tour between 12:30 PM and 3:30 PM on 9/02/2011, observation revealed the following:

1. The storage room next to the old elevator area, was not equipped with automatic fire sprinkler protection and,

2. The elevator room located on the northwest side of the building, was not equipped with automatic fire
sprinkler protection.

These findings were confirmed by the Safety Officer at the time of discovery.

Based on observations and interview, the facility has a cubicle curtain that does not meet the requirements in accordance with NFPA 25 (98) and NFPA 701 (99). This deficient practice could affect 4 patients, staff and visitors by hampering proper sprinkler coverage.

Findings include:

On facility tour between 12:30 PM and 3:30 PM on 9/02/2011, it was found that the cubicle curtain in patient room 220 did not meet the 1/2 inch diagonal mesh requirement in accordance with NFPA 25 (98) and NFPA 701.

This was confirmed by the Safety Officer.

Based on observation and interview, the facility had a room that did not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the safety of 4 patients, staff and visitors, if smoke were allowed to enter the exit access corridors making it untenable.

Findings include:

On facility tour between 12:30 PM and 3:30 PM on 9/02/2011, it was observed that the IT office did not have a door and was open to the corridor not meeting the requirements with LSC (00), Section 19.3.6.3.2.


This deficient practice was verified by the Safety Officer.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 19, Section 19.3.5. and Chapter 9, Section 9.7. This deficient pratice could affect all 4 patients, visitors, and staff.

FINDINGS INCLUDE:

On facility tour between 12:30 PM and 3:30 PM on 9/02/2011, observation revealed the following:

1. The storage room next to the old elevator area, was not equipped with automatic fire sprinkler protection and,

2. The elevator room located on the northwest side of the building, was not equipped with automatic fire
sprinkler protection.

These findings were confirmed by the Safety Officer at the time of discovery.

Based on observations and interview, the facility has a cubicle curtain that does not meet the requirements in accordance with NFPA 25 (98) and NFPA 701 (99). This deficient practice could affect 4 patients, staff and visitors by hampering proper sprinkler coverage.

Findings include:

On facility tour between 12:30 PM and 3:30 PM on 9/02/2011, it was found that the cubicle curtain in patient room 220 did not meet the 1/2 inch diagonal mesh requirement in accordance with NFPA 25 (98) and NFPA 701.

This was confirmed by the Safety Officer.