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Based on observation, the facility failed to properly maintain smoke barriers to provide compartmentation of the facility. This deficient practice could affect the safety of all patients, staff, and visitors, if smoke were allowed to pass from one smoke compartment to another.

Findings include:

On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was observed that the walls above the smoke barrier doors and smoke barrier walls above ceiling tiles had penetrations that had not been sealed in an approved manner in the following areas;
1) 2nd floor doors to surgery around pipes and conduit.
2) By room 201around pipes and conduit.
This deficiency was verified by the facility enviromental service staff ( MJ),

Based on observations, the facility has failed to provide proper protection from hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all patients, staff and visitors as smoke from a fire in this room could enter the corridor making it untenable.

Findings include:

On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was observed that:
1 ) 1st floor Biohazard Room had 2 8" x*' holes in the fire rated ceiling and a 1/2 " space around the sprinkler head.
2 ) Lower level Soiled Linen Room did not have a self closing device on the door for automatic closing.
3 ) Lower level Medical Records/ Storage room did not have a self closing device on the door for automatic closing.
This deficiency was verified by the facility environmental service staff ( MJ),

Emergency lighting of at least 1-1/2 hour duration is provided in accordance with 7.9,
18.2.9.1, 19.2.9.1, and 1999 NFPA 99 - 3-3.2.1.2(5e).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide reliable lighting for anesthetizing locations and as required by 2000 NFPA 101, Section 19..2.9.1, 7.9.3, 7.10.9 and 1999 NFPA 99 - 3-3.2.1.2.(5e). The deficient practice could affect all patients in these locations.

Findings include:
On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was observed that:no emergency lighting was present in operating rooms 1 and 2. During interview with facility staff ( MJ ), no testing of emergency lights in the operating was conducted and he did not know if the fixtures had battery back up.
This deficiency was verified by the facility environmental service staff ( MJ),

Based on review of available reports and records, it was determined that the facility has failed to properly conduct fire drills in accordance with NFPA 101 (00), Chapter 19, Section 19.7.1.2.. This deficient practice could affect how staff react in a fire emergency.

FINDINGS INCLUDE:
On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, during a review of fire drill reports provided by the facility. it was noted that the facility did have documentation that any fire drills were conducted during the last 12 months.
This deficiency was verified by the facility environmental service staff ( MJ),

Based on observation, the facility has failed to properly maintain the fire alarm system in accordance with NFPA 72, 1999 Edition. This deficient practice could affect all occupants including patients, staff and visitors during scheduled night shift drills throughout the year.

Findings include:
On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was revealed during review of available fire alarm documentation that the D.A.C.T. (Digital Alarm Communicator Transmitter) has not been tested in the last 12 months.
This deficiency was verified by the facility environmental service staff ( MJ),

Based on record review and interview the complete automatic fire sprinkler system is not being maintained in accordance with NFPA 25(99) Section 9.2.7. This deficient practice could effect all occupants of the building if the system were to fail under fire conditions.

Findings include:
On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was revealed during review of available fire sprinkler records that there was no documentation of quarterly sprinkler flow testing testing in the last 12 months. During an interview with facility staff ( MJ ), he did not know if testing was conducted.
This deficiency was verified by the facility environmental service staff ( MJ),

Based on observation the facility does not have a complete automatic extinguishment system over the cooking appliance as required by LSC(00) Section 19.3.2.6, LSC(00) Section 9.2.3 & NFPA 96. This deficient practice could effect all residents, staff and visitors, within the smoke compartment.

Findings include:
On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was observed that in the facility kitchen cook was melting butter on the stove. The hood system did not have a complete automatic extinguishment system with nozzles over the stove or griddle appliance as required.
This deficiency was verified by the facility environmental service staff ( MJ),

The facility failed to maintain the emergency generator in accordance with the requirements of NFPA 110 - 1999 edition and NFPA 99 - 1999 edition, section 3-4.1.1.2. This deficient practice could affect the safety of all patients, staff and visitors.

Findings include:
On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was revealed during review of available emergency generator records and interview with facility staff (MJ), that:
(1) No documentation provided that the emergency generator has not been tested under load on a monthly basis.
(2) No documentation provided that weekly inspections have been conducted.
This deficiency was verified by the facility environmental service staff ( MJ),







*TEAM COMPOSITION*
Tom Linhoff, Life Safety Code Spc.

Based on observation, the facility failed to properly maintain smoke barriers to provide compartmentation of the facility. This deficient practice could affect the safety of all patients, staff, and visitors, if smoke were allowed to pass from one smoke compartment to another.

Findings include:

On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was observed that the walls above the smoke barrier doors and smoke barrier walls above ceiling tiles had penetrations that had not been sealed in an approved manner in the following areas;
1) 2nd floor doors to surgery around pipes and conduit.
2) By room 201around pipes and conduit.
This deficiency was verified by the facility enviromental service staff ( MJ),

Based on observations, the facility has failed to provide proper protection from hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all patients, staff and visitors as smoke from a fire in this room could enter the corridor making it untenable.

Findings include:

On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was observed that:
1 ) 1st floor Biohazard Room had 2 8" x*' holes in the fire rated ceiling and a 1/2 " space around the sprinkler head.
2 ) Lower level Soiled Linen Room did not have a self closing device on the door for automatic closing.
3 ) Lower level Medical Records/ Storage room did not have a self closing device on the door for automatic closing.
This deficiency was verified by the facility environmental service staff ( MJ),

Emergency lighting of at least 1-1/2 hour duration is provided in accordance with 7.9,
18.2.9.1, 19.2.9.1, and 1999 NFPA 99 - 3-3.2.1.2(5e).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide reliable lighting for anesthetizing locations and as required by 2000 NFPA 101, Section 19..2.9.1, 7.9.3, 7.10.9 and 1999 NFPA 99 - 3-3.2.1.2.(5e). The deficient practice could affect all patients in these locations.

Findings include:
On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was observed that:no emergency lighting was present in operating rooms 1 and 2. During interview with facility staff ( MJ ), no testing of emergency lights in the operating was conducted and he did not know if the fixtures had battery back up.
This deficiency was verified by the facility environmental service staff ( MJ),

Based on review of available reports and records, it was determined that the facility has failed to properly conduct fire drills in accordance with NFPA 101 (00), Chapter 19, Section 19.7.1.2.. This deficient practice could affect how staff react in a fire emergency.

FINDINGS INCLUDE:
On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, during a review of fire drill reports provided by the facility. it was noted that the facility did have documentation that any fire drills were conducted during the last 12 months.
This deficiency was verified by the facility environmental service staff ( MJ),

Based on observation, the facility has failed to properly maintain the fire alarm system in accordance with NFPA 72, 1999 Edition. This deficient practice could affect all occupants including patients, staff and visitors during scheduled night shift drills throughout the year.

Findings include:
On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was revealed during review of available fire alarm documentation that the D.A.C.T. (Digital Alarm Communicator Transmitter) has not been tested in the last 12 months.
This deficiency was verified by the facility environmental service staff ( MJ),

Based on record review and interview the complete automatic fire sprinkler system is not being maintained in accordance with NFPA 25(99) Section 9.2.7. This deficient practice could effect all occupants of the building if the system were to fail under fire conditions.

Findings include:
On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was revealed during review of available fire sprinkler records that there was no documentation of quarterly sprinkler flow testing testing in the last 12 months. During an interview with facility staff ( MJ ), he did not know if testing was conducted.
This deficiency was verified by the facility environmental service staff ( MJ),

Based on observation the facility does not have a complete automatic extinguishment system over the cooking appliance as required by LSC(00) Section 19.3.2.6, LSC(00) Section 9.2.3 & NFPA 96. This deficient practice could effect all residents, staff and visitors, within the smoke compartment.

Findings include:
On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was observed that in the facility kitchen cook was melting butter on the stove. The hood system did not have a complete automatic extinguishment system with nozzles over the stove or griddle appliance as required.
This deficiency was verified by the facility environmental service staff ( MJ),

The facility failed to maintain the emergency generator in accordance with the requirements of NFPA 110 - 1999 edition and NFPA 99 - 1999 edition, section 3-4.1.1.2. This deficient practice could affect the safety of all patients, staff and visitors.

Findings include:
On facility tour between 08:30 AM and 03:00 PM on 06/06/2012, it was revealed during review of available emergency generator records and interview with facility staff (MJ), that:
(1) No documentation provided that the emergency generator has not been tested under load on a monthly basis.
(2) No documentation provided that weekly inspections have been conducted.
This deficiency was verified by the facility environmental service staff ( MJ),







*TEAM COMPOSITION*
Tom Linhoff, Life Safety Code Spc.