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Based on observation, the facility failed to provide protection of hazardous areas in accordance with the requirements of NFPA 101 -2000 edition, Section 18.3.6.2. This deficient practice could affect staff patients and visitors within this smoke compartment.

Findings include:
On facility tour between 09:00 AM and 04:00 PM on 07/16/2013, it was observed that
the 10th floor South Building Storage Room, S10643, is over 100 sq ft. and does not have an automatic closing, 45 minute fire rated corridor door as required.

Based on observation and interview, the facility failed to provide and maintain the vertical opening protection required by NFPA 101 - 2000 edition, Sections 19.3.1.1, 19.2.1, 19.2.2.3, 7.1.3.2, 7.1.3.2.3, 7.1.10.1, 7.2.2.5, 8.2.3, 8.2.3.1.1, 8.2.3.1.2, 8.2.3.2.3.1, 8.2.5 and 8.2.5.2, 8.2.5.3 and 8.2.5.4. This deficient practice could affect approximately 42 of the 1131 residents.

Findings include:
On facility tour between 09:00 AM and 04:00 PM on 07/17/2013, it was observed that
the 2nd floor stairwell exit door, #2676A, had a 1 inch hole in the top of the door and thatseveral holes have been drilled in the door frame assembly.

Based on observation and interview, it was determined that the facility failed to maintain its automatic sprinkler system in accordance with NFPA 101 - 2000 edition, Sections 19.3.5 and 9.7; NFPA 13 - 1999 edition, Section 6.1.1.5 and NFPA 25 - 1998 edition, Sections 2.2.1.1, 2-3.2 and 2-4.1.4. This deficient practice could affect the residents, staff and visitors within the smoke compartments.

Findings include:
On facility tour between 09:00 AM and 04:00 PM on 07/16/2013, it was observed that
Nurses Station C9100, the cubical walls are 84 inches high and are within 18 inches of the fire sprinkler heads which obstructs the fire sprinkler head coverage.

Based on observation and interview, the facility failed to maintain the emergency generator in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. This deficient practice could effect all patients.

Findings include:

During facility tour on 07/16/2013, observation revealed that the Remote Generator Annunciator Panel, located at the Operating Room Nurses Station, is in the trouble mode, and is not communicating with the generator.

This deficienct practice was verified by AP at the time of the inspection.

Based on observation, the facility failed to provide protection of hazardous areas in accordance with the requirements of NFPA 101 -2000 edition, Section 18.3.6.2. This deficient practice could affect staff patients and visitors within this smoke compartment.

Findings include:
On facility tour between 09:00 AM and 04:00 PM on 07/16/2013, it was observed that
the 10th floor South Building Storage Room, S10643, is over 100 sq ft. and does not have an automatic closing, 45 minute fire rated corridor door as required.

Based on observation and interview, the facility failed to provide and maintain the vertical opening protection required by NFPA 101 - 2000 edition, Sections 19.3.1.1, 19.2.1, 19.2.2.3, 7.1.3.2, 7.1.3.2.3, 7.1.10.1, 7.2.2.5, 8.2.3, 8.2.3.1.1, 8.2.3.1.2, 8.2.3.2.3.1, 8.2.5 and 8.2.5.2, 8.2.5.3 and 8.2.5.4. This deficient practice could affect approximately 42 of the 1131 residents.

Findings include:
On facility tour between 09:00 AM and 04:00 PM on 07/17/2013, it was observed that
the 2nd floor stairwell exit door, #2676A, had a 1 inch hole in the top of the door and thatseveral holes have been drilled in the door frame assembly.

Based on observation and interview, it was determined that the facility failed to maintain its automatic sprinkler system in accordance with NFPA 101 - 2000 edition, Sections 19.3.5 and 9.7; NFPA 13 - 1999 edition, Section 6.1.1.5 and NFPA 25 - 1998 edition, Sections 2.2.1.1, 2-3.2 and 2-4.1.4. This deficient practice could affect the residents, staff and visitors within the smoke compartments.

Findings include:
On facility tour between 09:00 AM and 04:00 PM on 07/16/2013, it was observed that
Nurses Station C9100, the cubical walls are 84 inches high and are within 18 inches of the fire sprinkler heads which obstructs the fire sprinkler head coverage.

Based on observation and interview, the facility failed to maintain the emergency generator in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4. This deficient practice could effect all patients.

Findings include:

During facility tour on 07/16/2013, observation revealed that the Remote Generator Annunciator Panel, located at the Operating Room Nurses Station, is in the trouble mode, and is not communicating with the generator.

This deficienct practice was verified by AP at the time of the inspection.