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Based on observation and testing, the facility failed to provide walls constructed with at least 1/2 hour fire resistance rating.

Findings Include:

While inspecting corridor walls on May 17, at appx 11:05 a.m. the surveyor observed penetrations in the following corridor walls:
1) On 2nd floor next to nurses station had penetration
around water lines.
2) On 2nd floor above rooms 206 and 205 had
penetrations around water lines.
3) Penetrations around water lines down resident
hallways.

These deficient practices have the potential of effecting the entire floor.

The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide walls constructed with at least 1/2 hour fire resistance rating.

Findings Include:

While inspecting corridor walls on May 17, at appx 11:05 a.m. the surveyor observed penetrations in the following corridor walls:
1) On 2nd floor next to nurses station had penetration around water lines.
2) On 2nd floor above rooms 206 and 205 had penetrations around water lines.
3) Penetrations around water lines down resident hallways.

These deficient practices have the potential of effecting the entire floor.

The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to maintain the two hour fire separation between nonconforming buildings. This deficiency had the potential to affect 25% of the residents and staff.

Findings Include:

While inspecting the separation wall on May 17, 2011 at appx. 1:00 p.m., the surveyor and maintenance director observed the two hour fire separation had an appx one half inch penetrations around the communication wires. The communication wires were not in a sleeve.

These deficient practices have the potential of effecting one smoke compartment in the hospital.

The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide walls constructed with at least 1/2 hour fire resistance rating.

Findings Include:

While inspecting corridor walls on May 17, at appx 11:05 a.m. the surveyor observed penetrations in the following corridor walls:
1) On 2nd floor next to nurses station had penetration
around water lines.
2) On 2nd floor above rooms 206 and 205 had
penetrations around water lines.
3) Penetrations around water lines down resident
hallways.

These deficient practices have the potential of effecting the entire floor.

The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide walls constructed with at least 1/2 hour fire resistance rating.

Findings Include:

While inspecting corridor walls on May 17, at appx 11:05 a.m. the surveyor observed penetrations in the following corridor walls:
1) On 2nd floor next to nurses station had penetration around water lines.
2) On 2nd floor above rooms 206 and 205 had penetrations around water lines.
3) Penetrations around water lines down resident hallways.

These deficient practices have the potential of effecting the entire floor.

The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide vertical openings that have a fire resistance rating of at least one hour.

Findings Include:

While inspecting vertical openings on May 17, 2011 at appx. 10:40 a.m., the surveyor observed deficient items in the following unsealed penetrations:
1) Penetration in the floor in the electrical room located
on the 3rd floor.
2) Penetrations in the floor in the mechanical room
located on the 3rd floor.
3) Penetrations in the floor in the mechanical room
located on the 2nd floor in surgery.

These deficient practices have the potential of effecting the entire facility.

The maintenance supervisor and the administrator were notified during an exit conference.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect about 50% of the residents and staff.

Findings include:

While inspecting smoke barrier walls on May 17, 2011 at appx. 12:05 p.m., the surveyor observed penetrations in the
following smoke barrier walls:
1) 3rd floor smoke barrier walls had numerous
penetrations.
2) 2nd floor above smoke barrier doors had penetrations
3) smoke barrier wall at hallway to newer addition had
penetrations across the top of the wall.
4) 1st floor above the pharmacy had penetrations in wall.

These 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 a properly installed, tested and maintained fire alarm system in accordance with NFPA 70 and NFPA 72. This condition affected 50% of the residents and staff.

Findings Include:

On May 17, 2011 at appx. 1:40 p.m., the maintenance person and surveyor found that the following horn/strobe did not function properly:
1.) The strobe located on the 3rd floor did not initiate when fire alarm was activated.
2.) The horn located on the 1st floor in the administration hallway did not initiate when the fire alarm was activated.

This deficient practices have the potential of effecting the occupants of the 1st and 3rd floor of the facility.

The maintenance supervisor and the administrator were notified during an exit conference.

Based on observations, the facility failed to provide a remote annunciator panel to generator serving the Type 1 Essential Electrical System. This deficiency had the potential to affect 100% of the residents and staff.

Findings Include:

During the survey on May 17, 2011 at appx. 2:00 p.m., the surveyor and the maintenance supervisor found no provision for monitoring the operational status of the emergency generator at a staffed remote location within the facility.

Specific Code: National Fire Protection Associations's (NFPA) 99, Health CareFacilities, 1999 Edition.

3-4.1.1.15 Alarm Annuciator
A remote annuciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)

The Annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure.
2. Low water temperature (below those required in 3-4.1.1.9).
3. Excessive water temperature.
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply.
5. Overcrank (failed to start).
6. Overspeed.
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110:3-5.5.2]

This deficient practices have the potential of effecting the entire facility.

The maintenance supervisor and the administrator were notified during an exit conference.