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Based on observation and interview, the provider failed to maintain the fire-resistive characteristics of the two hour fire-resistive wall/horizontal exit between the nursing home and the hospital. Findings include:

1. Observation at 11:15 a.m. on 6/28/11 revealed the two hour fire-resistive wall (horizontal exit) between the nursing home and the hospital had unsealed upright edges on the hospital side of the wall; spray foam insulation around two 2 inch conduits at both sides of the wall (unapproved sealant); and three open 1/2 inch conduits on the nursing home side of the two hour wall. All items were situated above the lay-in ceiling. Interview with the maintenance supervisor at the time of the observation confirmed those findings. He stated he would have the original contractor come back to the facility as soon as possible to make the needed corrections.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas for the boiler room and materials management/loading dock. Five openings around corridor wall pipe penetrations were not sealed with an appropriate firestop material. Findings include:

1. Observation beginning at 2:15 p.m. on 6/28/11 revealed openings around two penetrations of the corridor wall of the boiler room from 2 inch diameter insulated steam pipes that were not sealed with an approved firestop material. The 3/4 inch conduit for the boiler emergency stop button was not sealed with an approved firestop material. There were two transformer conduit penetrations of the corridor wall in materials management/loading dock that were not sealed with an approved firestop material. Interview with the maintenance supervisor at the time of the observations confirmed those findings.

Based on observation and interview, the provider failed to install emergency lighting of at least one and one-half hour duration. There was not a battery backup emergency light at the transfer switch locations for the generator. Findings include:

1. Observation at 3:30 p.m. on 6/28/11 revealed there was not a battery backup emergency light installed in the mechanical room at the transfer switch locations for the generator. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

Based on observation and interview, the provider failed to maintain the fire-resistive characteristics of the two hour fire-resistive wall/horizontal exit between the nursing home and the hospital. Findings include:

1. Observation at 11:15 a.m. on 6/28/11 revealed the two hour fire-resistive wall (horizontal exit) between the nursing home and the hospital had unsealed upright edges on the hospital side of the wall; spray foam insulation around two 2 inch conduits at both sides of the wall (unapproved sealant); and three open 1/2 inch conduits on the nursing home side of the two hour wall. All items were situated above the lay-in ceiling. Interview with the maintenance supervisor at the time of the observation confirmed those findings. He stated he would have the original contractor come back to the facility as soon as possible to make the needed corrections.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas for the boiler room and materials management/loading dock. Five openings around corridor wall pipe penetrations were not sealed with an appropriate firestop material. Findings include:

1. Observation beginning at 2:15 p.m. on 6/28/11 revealed openings around two penetrations of the corridor wall of the boiler room from 2 inch diameter insulated steam pipes that were not sealed with an approved firestop material. The 3/4 inch conduit for the boiler emergency stop button was not sealed with an approved firestop material. There were two transformer conduit penetrations of the corridor wall in materials management/loading dock that were not sealed with an approved firestop material. Interview with the maintenance supervisor at the time of the observations confirmed those findings.

Based on observation and interview, the provider failed to install emergency lighting of at least one and one-half hour duration. There was not a battery backup emergency light at the transfer switch locations for the generator. Findings include:

1. Observation at 3:30 p.m. on 6/28/11 revealed there was not a battery backup emergency light installed in the mechanical room at the transfer switch locations for the generator. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

Based on document review and interview, the provider's administrative policy did not state notification to the SD Department of Health, Office of Licensure and Certification via facsimile to (605) 773-6667 was required when the fire sprinkler system was out of service for more than 4 hours in a 24 hour period. Findings include:

1. Document review revealed the provider's administrative policy did not state notification to the SD Department of Health, Office of Licensure and Certification via facsimile was required when the fire sprinkler system was out of service for more than 4 hours in a 24 hour period. Notification by facsimile to (605) 773-6667 would be the approved method (other methods would be considered supplemental but not acceptable as the primary means of notification). Interview with the maintenance supervisor at 10:00 a.m. on 6/29/11 revealed the policies would be revised for compliance with the requirement.