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Based on observation, the facility failed to maintain a smoke barrier wall in conformance with NFPA 101 (2000), Chapter 19, Section 19.3.7 and Chapter 8, Section 8.3.4. In a fire emergency, this deficient practice could adversely affect 16 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 08/06/2013 between 10:00 AM and 4:30 PM, observation revealed the double cross-corridor smoke barrier doors located on the 2nd floor west egress corridor swung in the same direction, one door leaf was equipped with an astragal, and the overall assembly was lacking a door coordinator to assure that the door leaf without the astragal would always close first.

This finding was verified with the chief building engineer at the time of discovery.

Based upon a staff interview and review of available records, the facility was unable to achieve a minimum load of 30% of the EPS nameplate rating during monthly load testing of the emergency generator. In a fire or other emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 08/06/2013 between 10:00 AM and 4:30 PM, observation revealed the facility utilizes two (2) diesel-fired emergency generators. A review of the facility's monthly test logs for both generators confirmed that neither generator was exercised at not less than 30% of the EPS nameplate rating during every month of the previous year. Further, no documentation could be provided verifying the gensets were exercised using supplemental loads, i.e., load-banked, within the previous year. This deficient practice was not in conformance with the requirements at NFPA 110 (99) Sections 6-4.2 and 6-4.2.2.

This finding was confirmed with the chief building engineer.

Based on observation, the facility failed to maintain a smoke barrier wall in conformance with NFPA 101 (2000), Chapter 19, Section 19.3.7 and Chapter 8, Section 8.3.4. In a fire emergency, this deficient practice could adversely affect 16 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 08/06/2013 between 10:00 AM and 4:30 PM, observation revealed the double cross-corridor smoke barrier doors located on the 2nd floor west egress corridor swung in the same direction, one door leaf was equipped with an astragal, and the overall assembly was lacking a door coordinator to assure that the door leaf without the astragal would always close first.

This finding was verified with the chief building engineer at the time of discovery.

Based upon a staff interview and review of available records, the facility was unable to achieve a minimum load of 30% of the EPS nameplate rating during monthly load testing of the emergency generator. In a fire or other emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 08/06/2013 between 10:00 AM and 4:30 PM, observation revealed the facility utilizes two (2) diesel-fired emergency generators. A review of the facility's monthly test logs for both generators confirmed that neither generator was exercised at not less than 30% of the EPS nameplate rating during every month of the previous year. Further, no documentation could be provided verifying the gensets were exercised using supplemental loads, i.e., load-banked, within the previous year. This deficient practice was not in conformance with the requirements at NFPA 110 (99) Sections 6-4.2 and 6-4.2.2.

This finding was confirmed with the chief building engineer.